About the role

Provide analytical support and leadership for key internal Operations projects
Partner with the Operations departments to ensure all regulatory and compliance deliverables are met
Represent operations on cross-functional project work teams
Submit, monitor and prioritize IT tickets for the operations departments
Review special projects and identify issue trends and potential resolutions
Assist with reporting and processes that are regulatory related and tied to state issues deadlines
Assist with the development, drafting and review of P&P’s and job aides for Operations
Assist in educating/training Business Partners on operations functions
Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time
Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
Track all Compliance required training on a yearly and new hire basis for Operations
Assist with all readiness activities in relation to implementation of a new line of business for Operations

Requirements

Bachelor’s degree or equivalent years of relevant work experience required
Minimum of two (2) years of healthcare operations environment is required
Regulatory and/or compliance experience is preferred
Advanced level experience in Microsoft Word, Excel and PowerPoint
Data analysis and trending skills
Demonstrated understanding of claims operations specifically related to managed care
Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field
Critical listening and thinking skills
Negotiation skills/experience
Strong interpersonal skills
Proper grammar usage
Technical writing skills
Time management skills
Strong communication skills, both written and verbal
Customer service orientation
Decision making/problem solving skills

Benefits

comprehensive total rewards package

Hybrid Operations Regulatory Specialist II – Health Plan Experience, Facets Preferred

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