[Hiring] Healthcare Claims & Payment Operations Specialist @Tria Federal

Role Description

Tria Federal is seeking a Healthcare Claims & Payment Operations Specialist to support healthcare claims administration, payment integrity, and Primary Family Caregiver stipend-payment operations within a federal healthcare program. This role will provide operational oversight, analyze complex claims and payment issues, support quality assurance activities, and identify opportunities to improve payment accuracy, efficiency, and compliance.

Responsibilities

• Primary Family Caregiver Stipend Payments:
  • Support accurate and timely processing of stipend payments for Primary Family Caregivers in accordance with approved eligibility information, payment instructions, effective dates, and program-specific calculation requirements.
  • Validate payment inputs, reconcile scheduled and completed payments, investigate discrepancies, and support authorized payment adjustments and corrections.
  • Coordinate with caregiver program personnel and financial operations teams to resolve missing, delayed, duplicate, or inaccurate payments while maintaining appropriate supporting documentation.
  • Develop and maintain monitoring and quality controls to assess payment timeliness, calculation accuracy, unresolved exceptions, and changes impacting payment processing.
• Process Improvement, Documentation & Implementation:
  • Translate payment operations requirements into standard operating procedures (SOPs), process maps, business requirements, training materials, quality controls, and decision-support documentation.
  • Partner with technology teams to identify and define system enhancements, validate payment-related business rules, develop test scenarios, support user acceptance testing (UAT), and assess operational readiness.
  • Maintain issue logs, corrective-action plans, decision records, and performance dashboards while communicating operational risks and recommendations to Government leadership.
  • Ensure sensitive beneficiary, provider, clinical, and financial information is handled in accordance with approved security, privacy, and access procedures.

Qualifications

• Bachelor's degree in Healthcare Administration, Business Administration, Finance, Accounting, Nursing, Health Information Management, or a related discipline. Education substitutions must align with applicable contract requirements.
• Seven or more years of relevant experience in healthcare claims operations, payer payment administration, claims quality assurance, payment integrity, or government healthcare program operations.
• Demonstrated experience independently analyzing complex claims or payment issues, developing recommendations, and leading corrective actions or operational improvements.

Requirements

• Claims & Payment Expertise:
  • Hands-on experience across the healthcare claims lifecycle, including intake, validation, adjudication support, payment processing, reconciliation, denials or rejections, and dispute resolution.
  • Ability to distinguish between eligibility, authorization, clinical review, coverage, reimbursement, and payment-processing issues and engage appropriate stakeholders to resolve them.
  • Experience interpreting program requirements and translating them into operational procedures, review criteria, and documented business rules.
  • Experience evaluating payment accuracy, processing timeliness, backlogs, exceptions, and internal controls using operational and financial data.
• Consulting & Delivery:
  • Experience supporting a federal healthcare program, government payer, health plan, or third-party administrator (TPA) environment.
  • Strong written communication and stakeholder engagement skills, including the ability to develop executive briefings, case summaries, SOPs, and corrective-action plans.
  • Proficiency with Microsoft Office applications, including Excel, Word, PowerPoint, and Teams, as well as comparable reporting and workflow-management tools.
  • Ability to meet applicable Government suitability, background investigation, and information-access requirements.

Benefits

• Top-tier benefits package to invest in your physical, mental, and financial health and wellness.
• Opportunities to learn new skills, seize new challenges, and advance your career as we grow.