Remote Clinical Operations Specialist, Health Benefits

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

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