Claims Operations Specialist

$41,080 - $54,080/Yr

Aloha Care - Honolulu, HI

Full-time - Entry Level

Honolulu, HI

Ambulatory Health Care Services

About the position

The Claims Operations Specialist at AlohaCare is responsible for managing business processes within the claims department, focusing on Cost Share, Claims Recovery, and Claims Resolution. This role involves outreach to members and providers, collaboration with internal departments to resolve issues, and the creation of business process documentation. The position emphasizes improving claims processing accuracy and efficiency while ensuring compliance with healthcare regulations.

Responsibilities

• Manage member cost share business processes including outreach and claims adjustments.
• Research and analyze claims data to identify potential recoveries and resolve eligibility issues.
• Respond to provider inquiries and investigate claims processing issues.
• Develop monitoring reports for claims denial and recovery identification.
• Assist with documenting business requirements and conducting system testing.
• Support internal claims audit processes and assist with new hire training.

Requirements

• High school diploma or equivalent.
• Minimum of two years of claims processing experience or equivalent education and experience.
• Excellent verbal and written communication skills.
• Intermediate skills in Microsoft Word, Excel, and Outlook.
• Ability to read and interpret business documents related to claims and medical policies.
• In-depth knowledge of CPT, ICD-10, HCPCS, UB04, and CMS-1500 forms.

Nice-to-haves

• Bachelor's Degree in Business Administration, Accounting, or related field.
• Previous experience with Medical Claims Processing or Billing.
• Experience with QNXT and Medicaid or Medicare programs.
• Health care industry experience within managed care or medical office.
• Working knowledge of SQL Server Management Studio.

Benefits

• Health insurance
• Dental insurance
• Paid time off
• Vision insurance
• 401(k) matching
• Referral program