Clinical Operations Specialist - Remote Care & Compliance

GEHA; Lee's Summit (MO); Hybrid; USD 49.000 - 62.000; Vollzeit

Benefits dieser Stelle

Health/Vision/Dental benefits

401(k) with company match

Tuition Assistance Program

Hybrid/work-from-home options

Paid Time Off

Zusammenfassung

GEHA in the United States is seeking a remote-friendly Claims Specialist for Clinical Operations. The role involves identifying information from providers, reviewing claims for medical necessity, and escalating complex cases to senior staff.

Strong communication and Microsoft Office skills are essential. Candidates should have two years of college or healthcare experience, be located in the Kansas City metro area, and be able to maintain a dedicated home office with reliable high-speed internet.

Qualifikationen

• 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.
• Must reside in Kansas City Metropolitan area.
• Work-at-home requirements: must have high-speed internet and dedicated home office space.

Aufgaben

• 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.

Kenntnisse

Communication skills

Microsoft Office proficiency

Healthcare experience

Technology proficiency

Ausbildung

Two years of college (60 credits)

Tools

Microsoft Outlook

Microsoft Excel

Microsoft Word

Microsoft Teams

Jobbeschreibung

GEHA in the United States is seeking a remote-friendly Claims Specialist for Clinical Operations. The role involves identifying information from providers, reviewing claims for medical necessity, and escalating complex cases to senior staff.

Strong communication and Microsoft Office skills are essential. Candidates should have two years of college or healthcare experience, be located in the Kansas City metro area, and be able to maintain a dedicated home office with reliable high-speed internet.