Operations Specialist, Payment Integrity

About This Role

This role supports the Payment Integrity team by managing cost containment work streams across Medicare Advantage and Direct Contracting lines of business. The Operations Specialist will ensure accurate medical claims payment and recover overpayments to drive value for members.

Responsibilities

• Manage key elements of recovery workflows and communications to ensure accurate claims payment and efficient provider partnerships
• Support the team with daily operational tasks such as triaging and responding to provider disputes and inquiries
• Work cross-functionally with Payment Integrity, Claims, Provider Solutions, and other stakeholders to drive financial savings and maintain strong provider relationships
• Incorporate cross-functional perspectives and business needs in solving complex problems
• Support subject matter experts to improve team efficiency and maximize team ROI
• Contribute to process documentation and training (e.g., meeting minutes, workflows and standing operating procedures)

Requirements

• 1+ year of experience in healthcare, preferably in process improvement, operations, and/or analytics
• Ability to execute on daily tasks and priorities, effectively communicating progress to leadership
• Strong project management or administrative skills and the ability to multi-task while being highly organized and thorough
• Ability to regularly identify opportunities to implement efficient process/operational improvements
• Working knowledge of Excel
• Working understanding of healthcare topics pertaining to Network, such as physician reimbursement models, data sharing in provider partnerships, and PCP engagement

Qualifications

• 1+ year of experience in healthcare, particularly in process improvement, operations, and/or analytics

Skills

* Required skills

Benefits