Claims & Systems Support Specialist

Central Health; Austin (TX); On-site; USD 50,000 - 80,000; Full time

Job summary

Join a forward-thinking Health Maintenance Organization as a Claims & Claims System Support Specialist. In this pivotal role, you will enhance the claims management process through manual configuration and reporting, ensuring compliance with healthcare regulations. Collaborate with various departments to streamline operations and improve service delivery. This position offers an opportunity to make a significant impact in a dynamic environment focused on optimizing health plan functionality. If you are passionate about healthcare and have a knack for problem-solving, this role is perfect for you.

Qualifications

• 5 years of experience in Health Plan claims management.
• Thorough knowledge of healthcare regulatory compliance requirements.

Responsibilities

• Configure benefit plans in the claims management system based on design.
• Collaborate with Health Plan Departments to support their needs.

Skills

VBA Claim System

Communication Skills

Interpersonal Skills

Healthcare Regulatory Compliance

Education

High School Diploma or equivalent

Job description

Overview

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 coordinating functions.

Responsibilities

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.
2. 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.
3. Enrollment Management: Manual non-automated updates of the enrollment configuration to support the Health Plan.
4. Health Plan Department Coordination: Collaborate with Health Plan Departments, such as Clinical, Operations, Member Services, and Financial, to develop processes supporting their needs from the claims management software system.
5. 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.
6. Compliance Coordination: Coordinate with the Health Plan Compliance Department to ensure that the claims management system software meets all regulatory requirements.
7. Conduct review and evaluation of health plan claims received electronically and via mail.
8. 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

Qualifications

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

Experience: 5 years Health Plan claims. Required