Claims Operations Job Description

Claims Operations Job Description

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Claims operations provides technical and domain support to internal consultation process to answer technical questions and explain technical concepts.

Claims Operations Duties & Responsibilities

To write an effective claims operations job description, begin by listing detailed duties, responsibilities and expectations. We have included claims operations job description templates that you can modify and use.

Sample responsibilities for this position include:

Supports and executes team training for new partners driving ongoing learning opportunities for the team
Research Medicare Utilization kick out reports
Refer claims over to our phone team to contact the provider’s office for additional information
Make corrections to claims in CAS
Research and release pended claims
Research Action Requested reports
Work under the pressures of multiple yearly CMS deadlines
Have ability to change priorities depending on the inventory load
Participate in special projects as assigned by the Operations manager, FLL or TL’s
Manage a team of audit professionals to lead and execute IT audit plans (i.e., integrated audit, standalone application audit, and functional/horizontal thematic audit) as part of regional internal audit team

Claims Operations Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Claims Operations

List any licenses or certifications required by the position: I-CAR, ASE, PMP, ACF, CCP, CBAP, PMI, CMS

Education for Claims Operations

Typically a job would require a certain level of education.

Employers hiring for the claims operations job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Management, Business, Education, Financial Services, Leadership, Performance, Finance, Military, Associates, Business/Administration

Skills for Claims Operations

Desired skills for claims operations include:

Excel and Word
Technical concepts related to processing support software
Technical concepts pertaining to processing software
Technical writing concepts
Property claims contracts and interpretation of case law
Xactimate
Xactanalysis and Xact Contents
Microsoft office
Particularly Word & Excel
Excel

Desired experience for claims operations includes:

Experience working individual and/or group projects
Experience working in Microsoft Access databases
Manage day-to-day audit coverage (e.g., work papers review, audit scope proposal, budgeting, resource allocation, draft issues and reporting ) supporting financial and operational audit team
Maintain and continue enhancing clients’ relationships jointly with the IT Audit Director
Assist the IT Audit Director for continuous risk assessment and annual audit planning
Be a partner and counselor to all members of the team, regularly express a point-of-view, challenge and provide advice about risk and control considerations with a constructive and respected style

Claims Operations Examples

1

Claims Operations Job Description

Job Description Example
Our growing company is hiring for a claims operations. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims operations
  • All other duties as assigned Position specific Job Duties/Background Required
  • Must have healthcare administration experience, preferably within the government environment
  • Must have experience managing diverse populations of employees
  • Need ability to operate effectively at all levels, from managing front line employees to interacting with executives
  • Demonstrate ability to identify and implement efficiencies within an operations environment
  • Need ability to manage operational inventory to meet stated Service Level Agreements
  • Must conduct performance reviews and initiate progressive counseling, as appropriate
  • Monitor global carrier relationship management activity and ensuring that all activity is properly documented within claims relationship management (CRM) system
  • Communicate with Global Claims relationship managers to support their delivery and execution of the global claims strategy to assigned carriers and promote continued engagement
  • Create, update and maintain relationship management tracking tools and systems on behalf of the Global Claims leadership group
Qualifications for claims operations
  • Provides leadership to major projects and improvement efforts
  • Develop communication material to assist Global Claims relationship managers in proper articulation of Aon’s claims strategy and update as strategy evolves
  • Manage all carrier claims contacts within database to ensure data integrity and relevancy
  • Track carrier meeting schedules to ensure global claims engagement is ongoing and in line with the depth of ARS’s relationship with the carrier
  • Draft all claims governance and escalation agreement decks to ensure consistency in format and completeness of escalation leader information
  • Update/ upload material to the Global Claims SharePoint site to include items such as final documents related to the execution of Aon’s global claims strategy, carrier issued documents, Global Claims communications
2

Claims Operations Job Description

Job Description Example
Our innovative and growing company is looking for a claims operations. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claims operations
  • Prepare meeting material for global claims leadership team through collaboration with the Global Claims Insight Center, business research team and others in conjunction with independent due diligence
  • Assist in the creation of high quality presentation material, marketing collateral, carrier and / or client facing material and other documents for Global Claims leadership team to include formatting, graphics, content peer review, appropriate Aon branding
  • Contribute to the development of claims related insight for clients, carriers and colleagues
  • Manage the escalation and resolution process with external vendors to ensure appropriate turnaround times
  • Knowledge of general healthcare industry procedures
  • Extensive knowledge of client-specific metrics and performance goals
  • Understanding of key drivers of that affect performance across Claims and Contact Center to bring improvements to the overall customer Experience
  • Execute project deliverables to achieve budget targets, managing people, P&L, and customer service and satisfaction levels
  • Workforce planning and people management regarding workload, transitions, and other client requirements
  • Comfortable being hands on building new technologies, new business processes, and new operational support materials
Qualifications for claims operations
  • Delivery orientated with the ability to meet challenging deadlines on a regular basis
  • Bachelor degree in accounting, finance or other related field required
  • Possesses specialized industry knowledge (Medicaid, Managed Care, claims, encounter data)
  • Demonstrated high level of expertise with Medicaid regulations
  • Ability to understand claims adjudication, systems and reporting
  • Knowledge of claims pricing/reimbursement, claims, systems and refunds
3

Claims Operations Job Description

Job Description Example
Our company is growing rapidly and is looking to fill the role of claims operations. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claims operations
  • Conduct regular meetings with all WorkStream leads across the Polaris program on progress and strategy
  • Conduct weekly and / or biweekly meetings with all Product Owners related to specific efforts on project status
  • Lead strategy assessment, development and/or revision for specific project elements
  • Serve as a primary resource and subject matter expert related to Claim Domain project efforts
  • Assist in the development and training of any required procedures and policies to ensure understanding in project business requirements across Operations
  • Support Claim Domain efforts around strategy meetings, agenda development, meeting & materials preparation, presentation development
  • Monitor issues and risks- develop contingency or mitigation plans
  • Provide weekly project status reporting
  • Assist in process flow mapping as the Product Owner
  • Utilize Agile and Lean processes in the Project Management and Program Management process
Qualifications for claims operations
  • Working knowledge and/or certification in medical terminology, CPT-4 and ICD-9/10, preferred
  • Experience working with Medicaid managed care programs or experience working at a health plan in an operational capacity (claims, IT, finance) or experience working with data and work flows/logistics
  • Understanding of medical record review processes and coding desirable (credentials a plus)
  • Solid understanding of informational systems
  • Understanding of and experience with relational databases (SQL) is a plus
  • Displays planning and organizational skills by establishing plans of action for each engagement and delegating assignments appropriately based on individuals’ abilities (Works with the Senior Manager to review, correct, and provide direction to ensure proper completion of work)
4

Claims Operations Job Description

Job Description Example
Our company is growing rapidly and is looking for a claims operations. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for claims operations
  • Serve as process expert to identify and approve process changes impacting the Claim Domain operations
  • Leads and manages the M&R Claims Reporting function
  • Hires, on-boards, manages and engages a high-performing team of employees with a deep understanding of the COSMOS platform and workflows and SQL Server coding and reporting expertise
  • Leads the intake, analysis and translation of data and reporting needs from a diverse, cross-functional business partners requiring accurate and timely information to manage core operations functions and/or support M&R Operations or M&R CAG Business Plan initiatives or Strategic Plan projects
  • Implements and drives cross training and succession planning plans to ensure that there is a sufficient pipeline of COSMOS Platform and Reporting subject matter experts to meeting short- and long-term business needs
  • Manages staff performance
  • Ensuring all SLAs are met and scheduling staff accordingly
  • Objective results and office performance
  • Working with business representatives to define the project outcomes, aligned to business priorities and Operational plans
  • Serve as primary point of contact and liaison with other Global Claims Operations teams supporting North America Claims and non-claims functions to ensure alignment (e.g., Shared Services, Claims TPA/Delegated Authorities, PMO, Quality Assurance, Underwriting, Claims Legal, Accounting, Finance, Tax, Compliance)
Qualifications for claims operations
  • Experience in writing Policies and Procedures, explaining same to staff and developing training sessions to assure the TPA Claims Functionality remains at the highest level of learning and performance
  • Claims processing and/or CAS system experience
  • Experience training associates on processes
  • 5 + years of Health Care experience, Medicaid preferred
  • Operational Management / Leadership experience with direct / indirect reports up to 60 Managers and Transaction Processors
  • Examples where you implemented process improvements to achieve more desirable results
5

Claims Operations Job Description

Job Description Example
Our company is looking to fill the role of claims operations. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims operations
  • End User Support – coordinate new hire system training and serve as main point of contact for all end user system access and support inquires
  • Develops strategy for regional claims offices and implements plans to improve claim performance and control costs
  • Ensures effective coverage determinations, negotiations, reserving and settlement
  • Maintains and enhances the Medicare & Retirement Reporting Suite develop / maintain expert level knowledge of the COSMOS platform and core claims processing workflows and operational processes
  • Conducts root cause analysis on claims that contribute to decrease in performance and failure to meet commitments to understands reasons for not meeting state requirements, developing action planto address the issues / gaps with the cross functional teams
  • Manages the continuing review of present systems and methods, the formulation of new and revised systems
  • Analyze, track and trend claims and encounters data
  • Reviews pending work on a regular basis and makes contact with insureds, agents and vendors to determine progress and communicate status
  • Coordinates development of Claims forms and letters and serves as department resource on forms and letter issues
  • As part of the Home Office Catastrophe team, maintains employee information and activates Claims Assistants as requested
Qualifications for claims operations
  • Monitors and tracks resolution of issues
  • As needed, manage mass changes to Benefit Codes (BPL) as it relates to new projects, programs or regulatory changes
  • As needed, support Medispan updates (New NDCs) by analyzing data and submitting appropriate tickets to Benefit Operations / Formulary Operations
  • As needed, Support Service Teams in resolving group and global PDL / Drug Lists inaccuracies
  • 3+ years of Pharmacy Benefits Management (PBM) experience
  • Identifies resolves issues and roadblocks inhibiting completion of milestones

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