Remote Clinical Operations Specialist - Care & Claims

Government Employees Health Association, Inc.; United States; Remote; USD 49.000 - 62.000; Vollzeit

Benefits dieser Stelle

Health/Vision/Dental benefits

401(k) company match

Paid Time Off

Tuition Assistance Program

Hybrid/work-from-home options

Life and disability insurance

Well-being program

Zusammenfassung

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits to millions of federal employees and retirees, and their families.

This remote opportunity supports care management by coordinating claims, assessing medical necessity, and communicating with providers, members, and internal teams. The role requires two years of college or healthcare experience, strong Microsoft Office skills, and excellent written and verbal

Qualifikationen

• Two years of college or 2 years healthcare experience required.
• Intermediate proficiency with technology applications.
• Experience using Microsoft Office products (Outlook, Excel, Word, Teams).
• Effective written and verbal communication skills.
• Must reside in Kansas City Metropolitan area.

Aufgaben

• Uses communication methods to identify and solicit information from providers and vendors related to clinical and business needs.
• Coordinates, reviews and investigates claims to determine medical necessity and appropriateness of care.
• Determines simple cases requiring review by Medical Director, Pharmacist or nurse.
• Interprets medical review results to ensure compliance with contract provisions.
• Reports suspicions of compliance, clinical, quality, and regulatory concerns.
• Identifies cases for care and cost management.
• Recommends benefit allowances in line with contract liabilities.
• Engages in communication with internal and external customers regarding care management, products, and services.
• Directs processing of contractual benefits after investigation.
• Escalates complex cases to a senior team member.

Kenntnisse

Verbal and written communication

Microsoft Office proficiency

Technology proficiency

Ausbildung

Two years college or 2 years healthcare experience

Tools

Microsoft Office Suite

Jobbeschreibung

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits to millions of federal employees and retirees, and their families.

This remote opportunity supports care management by coordinating claims, assessing medical necessity, and communicating with providers, members, and internal teams. The role requires two years of college or healthcare experience, strong Microsoft Office skills, and excellent written and verbal