Claims & Systems Support Specialist

CommUnityCare; Austin (TX); On-site; USD 45,000 - 75,000; Full time

Job summary

An established industry player in health maintenance seeks a Claims & Claims System Support Specialist to optimize claims processing. In this role, you will implement manual configurations and collaborate with various departments to enhance the claims management system. Your expertise in healthcare regulatory compliance and proficiency with the VBA Claim System will be vital in ensuring accurate claims processing and adherence to regulations. Join a dedicated team focused on delivering high-quality support and improving operational efficiency in a dynamic healthcare environment.

Qualifications

• Minimum of 5 years of experience in Health Plan claims processing.
• High School Diploma or equivalent required; higher degrees accepted.

Responsibilities

• Manually update and create benefit plans in the claims management system.
• Collaborate with departments to develop processes supporting their needs.

Skills

VBA Claim System

Communication Skills

Interpersonal Skills

Healthcare Regulatory Compliance

Education

High School Diploma

Higher Degrees

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 manual non-automated configuration processes and report designs within the claim management system software to optimize claims processing and coordinate functions.

Responsibilities

1. Plan Design Configuration: Manually update and create benefit plans in the claims management system based on plan design provided by the Health Plan Benefit Team.
2. Provider Contract Configuration: Manually update and create contracted Provider’s fee schedules in the claims management system as provided by the Health Plan Provider Network Team.
3. Enrollment Management: Manually update enrollment configurations to support the Health Plan.
4. Health Plan Department Coordination: Collaborate with departments such as Clinical, Operations, Member Services, and Financial to develop processes supporting their needs within the claims management software system.
5. System Enhancements and Training: Attend training sessions with the software vendor to understand system updates and train relevant departments on changes affecting their functionality.
6. Compliance Coordination: Work with the Compliance Department to ensure the system meets all regulatory requirements.
7. Claims Review: Review and evaluate health plan claims received electronically and via mail.
8. Collaboration: Work with the Claims Management Team and other teams to ensure adjudication accuracy when necessary.

Knowledge, Skills, and Abilities

• Proficiency with 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 required; higher degrees accepted.
• Experience: Minimum of 5 years of experience in Health Plan claims processing.