Health Claims Operations Specialist

32bjfunds; New York (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

32BJ Benefit Funds is seeking a Health Operations Claims Specialist to support high-volume claims processing for 180,000+ plan participants. You will serve as a claims SME, work with members, providers, vendors, and internal teams to ensure accurate and timely processing, and help resolve complex claims while maintaining confidentiality and quality standards.

The role emphasizes analyzing claims, applying plan design rules, and supporting continuous improvement efforts within the Health Fund's

Qualifications

• 2+ years of work experience in health insurance claims, claims operations, or health billing.
• Extensive knowledge of claim processing policies and procedures, including hospital/medical claims, ICD-10/CPT/HCPCS coding, DRG coding, provider ids, amounts paid, and out-of-pocket costs.
• Strong knowledge of medical terminology and coding.
• Experience with healthcare regulations and claims compliance preferred.

Responsibilities

• Maintain deep expertise of the Fund's covered benefits.
• Evaluate claims for eligibility and plan design compliance.
• Research claims and third-party policies to understand impact of plan specifications.
• Collaborate with the vendor's claims processing team to review eligibility and processing issues.
• Identify and resolve claims problems and document root causes for management reports.
• Conduct member outreach to address claims inquiries and resolve issues.
• Communicate with facilities and providers regarding complex submissions and documentation.

Skills

Health insurance claims knowledge

Analytical skills

Communication skills

Problem-solving

Process improvement

MS Office proficiency

Education

High School Diploma/GED or equivalent

Tools

MS Office (Word/Excel/PowerPoint)

Job description

32BJ Benefit Funds is seeking a Health Operations Claims Specialist to support high-volume claims processing for 180,000+ plan participants. You will serve as a claims SME, work with members, providers, vendors, and internal teams to ensure accurate and timely processing, and help resolve complex claims while maintaining confidentiality and quality standards.

The role emphasizes analyzing claims, applying plan design rules, and supporting continuous improvement efforts within the Health Fund's