Clinical Operations Specialist

GEHA Health; United States; Remote; USD 49,000 - 62,000; Full time

Benefits offered by this job

Competitive pay

Incentive plan

Health/Vision/Dental benefits

401(k) company match + discretionary

Well-being program

Paid Time Off

Community enrichment time

Life and AD&D insurance

Short-Term & Long-Term Disability

Tuition assistance

Job summary

GEHA Health in the United States is seeking a detail-oriented administrative professional to support Clinical Operations. You will engage with members and providers, coordinate claims review, and assist in cost management and benefit determinations.

Strong written and verbal communication are essential, with a requirement to reside in the Kansas City metropolitan area for this remote role. The position emphasizes interpreting medical reviews, ensuring contract compliance, and escalating complex

Qualifications

• Requires two years (60 credit hours) of college or 2 years of healthcare experience.
• Requires intermediate proficiency with technology applications and systems.
• Requires experience using Microsoft Office products, i.e., Outlook, Excel, Word, Teams.
• Requires effective written and verbal communication skills.
• Must reside in Kansas City Metropolitan area.

Responsibilities

• Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
• Coordinates, reviews and investigates claims to determine medical necessity and appropriateness of care.
• Determines simple cases that require review by Medical Director, Pharmacist or nurse.
• Interprets medical review results to determine compliance with contract provisions.
• Reports suspicions of compliance, clinical, quality, and regulation concerns.
• Identifies cases for care and cost management.
• Recommend benefit allowances in alignment with contract liabilities.
• Engages in communication with internal and external customers regarding care management, products, and services.
• Directs processing of contractual benefits after investigation is complete.
• Escalates complex cases to senior team member.

Tools

Microsoft Office

Outlook

Excel

Word

Teams

Job description

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.

G.E.H.A has one mission: To empower federal workers to be healthy and well.

Performs routine administrative workflow tasks that support functions of Clinical Operations. Engages and educates members and providers about G.E.H.A benefits and programs. Identifies cases for internal and external Clinical programs.

SKILLS

Role Responsibilities

• Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
• Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
• Determines simple cases that require review by Medical Director, Pharmacist or nurse.
• Interprets medical review results to determine compliance with contract provisions.
• Reports suspicions of compliance, clinical, quality, and regulation concerns
• Identifies cases for care and cost management
• Recommend benefit allowances in alignment with contract liabilities
• Actively engages in communication and response with internal and external customers regarding care management, products, and services
• Directs processing of contractual benefits after investigation is complete
• Escalates complex cases to senior team member.

Requirements

• Requires two years (60 credit hours) of college or 2 years of healthcare experience.
• Additional years of qualifying work experience may be considered in lieu of formal education.
• Requires intermediate proficiency with technology applications and systems.
• Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams.
• Requires effective written and verbal communication skills.
• Must Reside in Kansas City Metropolitan area.

Work-at-home requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

How we value you

• Competitive pay/salary ranges
• Incentive plan
• Health/Vision/Dental benefits effective day one
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
• Robust employee well-being program
• Paid Time Off
• Personal Community Enrichment Time
• Company-provided Basic Life and AD&D
• Company-provided Short-Term & Long-Term Disability
• Tuition Assistance Program

While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.

Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity as well as, market and business considerations when extending an offer.

The target hiring range for this position is $48,771 - $61,698 USD. At G.E.H.A, the current maximum salary for this role is $68,749 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization.

G.E.H.A is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. G.E.H.A will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees.

G.E.H.A is headquartered in Lee’s Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.