Overview As the Claims & Claims System Support Specialist for a Health Maintenance Organization (HMO) and other Health Plans based in Texas, you will implement within the claim management system software the manual nonautomated configuration process and report design as needed to optimize the claims process and coordinating functions.
Responsibilities
Essential Functions: - Plan Design Configuration: Manual non-automated updates and creation of benefit plans in the claims management system software based on plan design provided by the Health Plan Benefit Team.Provider Contract Configuration: Manual non-automated updates and creation of the contracted Provider's fee schedule in the claims management system software provided by the Health Plan Provider Network Team.
- Enrollment Management: Manual non-automated updates of the enrollment configuration to support the HealthPlan.
- Health Plan Department Coordination: Collaborate with Health Plan Departments, such as Clinical, Operations, Member Services and Financial to develop processes to support their needs from the claims management software system.
- System Enhancements and Training: Attend training sessions with the claims management system software vendor to understand system changes and enhancements. Train Health Plan Departments on claims management system software changes that effect their functionality.
- Compliance Coordination: Coordinate with the Health Plan Compliance Department to ensure that the claims management system software is meeting all regulatory requirements.
- Conduct review and evaluation of health plan claims received electronically and via mail.
- Collaborating with Claims Management Team or other Health Plan Teams to ensure adjudication accuracy when needed.
Knowledge, Skills and Abilities: - VBA Claim System
- Excellent communication and interpersonal skills
- Thorough knowledge of healthcare regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations
Qualifications
Education: High School Diploma or equivalent (higher degree accepted). Required
Experience: 5 years Health Plan claims. Required