Operations Specialist, Senior (Medicare Claims)

Your Role

The Medicare Operations Claims team reviews and resolves Medicare claims processing questions and issue requests. This includes conducting comprehensive analyses, assessing impact, and implementing appropriate remediation at both the individual claims and plan levels. The Operations Specialist Senior will report to the Claims Operations Director. In this role you will identify claims processing issues, perform root cause analysis, and provide remediation based on findings. You will also work independently and collaboratively with internal teams to develop solutions that improve operational efficiency while ensuring compliance with state, federal, and local policies and provisions.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Requires a minimum of 5 years of relevant experience.
• Requires Medicare claims knowledge and processing experience
• Demonstrates strong verbal and written communication skills.
• Ability to work independently and operate as a self-starter who takes initiative.
• Exhibits strong critical thinking and problem-solving skills.
• Demonstrates strong prioritization and multi-tasking abilities.
• Maintains overall accountability and ensures tasks are followed through to completion.
• Possesses advanced knowledge of the job area, typically gained through a combination of advanced education and experience; may include practical project management knowledge.

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Your Work

In this role, you will:

• Serve as subject matter expert to review complex workflows, identify issues, and drive process improvements.
• Ensure claims processing aligns with CMS requirements and compliance standards.
• Monitor, document, and communicate workflow and system changes to stakeholders.
• Evaluate systems/applications and recommend enhancements or corrective actions.
• Develop tools, processes, and reporting to improve efficiency, accuracy, and visibility.
• Lead training, documentation, and guideline development; educate on complex topics.
• Operate independently while managing projects and providing guidance, coaching, and cross-functional collaboration.

Your Work

In this role, you will:

• Serve as subject matter expert to review complex workflows, identify issues, and drive process improvements.
• Ensure claims processing aligns with CMS requirements and compliance standards.
• Monitor, document, and communicate workflow and system changes to stakeholders.
• Evaluate systems/applications and recommend enhancements or corrective actions.
• Develop tools, processes, and reporting to improve efficiency, accuracy, and visibility.
• Lead training, documentation, and guideline development; educate on complex topics.
• Operate independently while managing projects and providing guidance, coaching, and cross-functional collaboration.