Claims & Systems Support Specialist

Central Health; Austin (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

A leading health organization in Texas seeks a Claims & Systems Support Specialist to optimize their claims process. This role involves configuring the claims management system, collaborating with various departments, and ensuring compliance with healthcare regulations. The ideal candidate will have strong communication skills and experience in health plan claims.

Qualifications

• 5 years of experience in Health Plan claims required.

Responsibilities

• Manual updates and creation of benefit plans in claims management system.
• Collaborate with Health Plan Departments to support their needs.
• Ensure compliance with regulatory requirements.

Skills

VBA Claim System

Communication

Interpersonal Skills

Healthcare Regulatory Compliance

Education

High School Diploma

Job description

Join to apply for the Claims & Systems Support Specialist role at Central Health.

As the Claims & Claims System Support Specialist for a Health Maintenance Organization (HMO) and other Health Plans based in Texas, you will implement within the claim management system software the manual non-automated configuration process and report design as needed to optimize the claims process and coordinate functions.

Essential Functions

1. Plan Design Configuration: Manual non-automated updates and creation of benefit plans in the claims management system software based on plan design provided by the Health Plan Benefit Team. Provider Contract Configuration: Manual non-automated updates and creation of the contracted Provider’s fee schedule in the claims management system software provided by the Health Plan Provider Network Team.
2. Enrollment Management: Manual non-automated updates of the enrollment configuration to support the Health Plan.
3. Health Plan Department Coordination: Collaborate with Health Plan Departments, such as Clinical, Operations, Member Services, and Financial, to develop processes to support their needs from the claims management software system.
4. System Enhancements and Training: Attend training sessions with the claims management system software vendor to understand system changes and enhancements. Train Health Plan Departments on claims management system software changes that affect their functionality.
5. Compliance Coordination: Coordinate with the Health Plan Compliance Department to ensure that the claims management system software meets all regulatory requirements.
6. Review and evaluate health plan claims received electronically and via mail.
7. Collaborate with Claims Management Team or other Health Plan Teams to ensure adjudication accuracy when needed.

Knowledge, Skills, and Abilities

• VBA Claim System
• Excellent communication and interpersonal skills
• Thorough knowledge of healthcare regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations

Education

High School Diploma or equivalent (higher degree accepted). Required.

Experience

5 years of experience in Health Plan claims. Required.

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Finance and Sales

Industries

• Hospitals and Health Care