Claims & Systems Support Specialist

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

Job summary

Join a forward-thinking health organization as a Claims & Claims System Support Specialist. In this role, you will optimize the claims process by implementing manual configurations in the claims management system. Your expertise in healthcare regulatory compliance and strong communication skills will be vital as you collaborate with various departments to ensure seamless operations. This position offers a unique opportunity to enhance your career while contributing to a vital healthcare mission, making a difference in the lives of many. If you are passionate about healthcare and have a knack for system management, this role is perfect for you.

Qualifications

• 5 years of experience in Health Plan claims management.
• High School Diploma or equivalent required.

Responsibilities

• Configure and update benefit plans in the claims management system.
• Collaborate with Health Plan Departments for system support.
• Ensure compliance with healthcare regulations.

Skills

VBA Claim System

Excellent communication skills

Interpersonal skills

Healthcare regulatory compliance

HIPAA knowledge

CMS guidelines knowledge

Texas regulations knowledge

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 nonautomated configuration process and report design as needed to optimize the claims process and coordinating functions.

Responsibilities

Essential Functions:

• 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.
• Enrollment Management: Manual non-automated updates of the enrollment configuration to support the HealthPlan.
• 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.
• 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 effect their functionality.
• Compliance Coordination: Coordinate with the Health Plan Compliance Department to ensure that the claims management system software is meeting all regulatory requirements.
• Conduct review and evaluation of health plan claims received electronically and via mail.
• Collaborating 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