[Hiring] Clinical Operations Specialist @GEHA Health

Role Description

Performs routine administrative workflow tasks that support functions of Clinical Operations. Engages and educates members and providers about G.E.H.A benefits and programs. Identifies cases for internal and external Clinical programs.

• 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 the medical necessity and appropriateness of the 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.
• Recommends benefit allowances in alignment with contract liabilities.
• Actively engages in communication and response 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.

Qualifications

• Requires two years (60 credit hours) of college or 2 years of healthcare experience.
• Additional years of qualifying work experience may be considered in lieu of formal education.
• 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.

Requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms.
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Benefits

• Competitive pay/salary ranges.
• Incentive plan.
• Health/Vision/Dental benefits effective day one.
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution.
• Robust employee well-being program.
• Paid Time Off.
• Personal Community Enrichment Time.
• Company-provided Basic Life and AD&D.
• Company-provided Short-Term & Long-Term Disability.
• Tuition Assistance Program.