Remote Clinical Operations Specialist

GEHA Health; Lee's Summit (MO); Remote; USD 49,000 - 62,000; Full time

Benefits offered by this job

Competitive pay/salary ranges

Incentive plan

Health/Vision/Dental benefits

401(k) match

Well-being program

Paid Time Off

Community enrichment

Life and AD&D

Disability insurance

Tuition assistance

Job summary

GEHA Health is seeking a remote administrative professional to support Clinical Operations. You will engage with providers and members, review claims, and determine medical necessity according to contract provisions.

The role requires two years of college or healthcare experience, solid tech skills, and excellent written and verbal communication. GEHA offers competitive pay, benefits from day one, and a hybrid-friendly culture in the Kansas City area.

Qualifications

• Requires two years of college or 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 (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
• 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.

Skills

Microsoft Office proficiency

Healthcare experience

Communication skills

Education

Two years college or healthcare experience

Tools

Microsoft Office

Job description

GEHA Health is seeking a remote administrative professional to support Clinical Operations. You will engage with providers and members, review claims, and determine medical necessity according to contract provisions.

The role requires two years of college or healthcare experience, solid tech skills, and excellent written and verbal communication. GEHA offers competitive pay, benefits from day one, and a hybrid-friendly culture in the Kansas City area.