Operations Specialist

NOT A REMOTE POSITION

The Operations Specialist resolves claims repricing disputes, researches provider participation, processes claims incurred by

incarcerated inmates for correction facilities, ensures discounts are applied to qualified medical services rendered and billed to Clients and paid to Providers, addresses questions, and generates applicable status reports.

Essential Job Functions

• Reviews claim dispute information i.e. EOB, claim form, and Provider appeals
• Researches PHS's Provider contracts and other documents to determine an accurate resolution
• Communicates resolution with Clients, Providers, and Affiliate Networks in a professional/timely manner
• Accurately logs claim disputes based on the submitted EOB and claim form
• Answers Provider phone/email inquiries
• Meets established monthly dispute resolution goals
• Discusses difficult resolutions in a calm/professional tone
• Maintains integrity by determining the most accurate resolution for disputed claims
• Works with other Operations Specialists and other internal departments on projects as necessary

• Must possess a High School Diploma or GED; an Associate's or Bachelor's Degree in Business or related field of study from an accredited college or university is preferred
• 2 years of clerical / customer service work experience in a health care related environment
• Demonstrated proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook

Competencies

• Excellent communication skills (written/oral) and the ability to effectively and logically exchange information
• Organized, detailed focused, ability to multitask and perform in a deadline driven environment
• Demonstrate tact, diplomacy, and confidentiality when dealing with others and managing sensitive issues including HIPAA Guidelines
• Excellent critical thinking and problem-solving skills (attention to detail)

Benefits

• Medical Insurance (high deductible plan with an HSA)
• Dental Insurance
• Vision Insurance
• Short-term and long-term disability paid by the company
• Group term life paid by the company
• PTO - 160 hours (4 weeks) with the ability to roll over 40 hours and cash out 40 hours at the end of the year
• Fitbit program with monetary rewards
• Employee recognition programs with monetary rewards
• Corporate office amenities - specialty coffee machines, assorted tea options, smoothie bar, collaborative workspaces, fruit provide by company and an onsite market
• Regular employee events such as potlucks, video game tournaments, door decorating contests, Mental Health Awareness Month activities, and a company carnival just to name a few of our past events

About Us

Prime Health Services (PHS) is a national medical cost containment company with a noteworthy PPO Network used by insurance carriers, TPA's, self-insureds, and governmental entities. Our tech-focused nature allows clients to take advantage of the flexibility of customization while not compromising on bill processing speed. Since 2001, we have specialized in medical provider network development and offer clients a tailored approach to medical cost containment: quality health care at discounted rates.

PIbcb0f4475a39-5107