Operations Specialist

Job Description

Job Description

South Country Health Alliance has an immediate need for an Operations Specialist at our Medford Office!

The Operations Specialist serves as the primary point of contact for member issue research and resolution regarding eligibility, claims and other assigned work within the organization and with outside partners. The position supports the operations department through effective communication and coordination in the exchange of information and data internally and externally to meet operational goals and reporting requirements. The Operations Specialist utilizes internal and external systems to run reports, obtain data and monitor work and works closely with operations department managers to review and complete assigned reports.

Requirements include an associate or bachelor’s degree in health care administration, business administration, or related industry and one year experience in healthcare administration, pharmacy, or related industry required. Three years’ experience in the above is considered in lieu of degree.

Basic knowledge of State and Federal programs (Medical Assistance and Medicare Part D) is preferred.

South Country offers a full range of comprehensive benefits such as medical, dental, vision, and more as well as competitive pay.

This position is a grade 5 and salary ranges from a minimum of $24.21 to $28.76 / hour, based on experience.

POSITION DESCRIPTION (Non-Exempt)

Position Title : Operations Specialist

Dept : Operations

Reports To : Director of Operations

Date : February 2025

Required : Associate or bachelor’s degree in health care administration, business administration, or related industry and one year experience in healthcare administration, pharmacy, or related industry required. Three years’ experience in the above is considered in lieu of degree.

Preferred : Basic knowledge of State and Federal programs (Medical Assistance and Medicare Part D) preferred.

Skill Sets : Possess critical thinking skills, problem solving, attention to detail, ability to understand complex processes; Ability to represent South Country Health Alliance to its Third Party Administrators (TPAs) and regulatory entities in a professional manner; Possess excellent interpersonal, verbal and written skills; Ability to multi-task; Excellent organization, prioritization, and time management skills; Proficient in Microsoft Office Suite, to include ability to work with a variety of systems and file formats.

JOB SUMMARY :

The Operations Specialist serves as the primary point of contact for member issue research and resolution regarding eligibility, claims and other assigned work within the organization and with outside partners. The position supports the operations department through effective communication and coordination in the exchange of information and data internally and externally to meet operational goals and reporting requirements. The Operations Specialist utilizes internal and external systems to run reports, obtain data and monitor work and works closely with operations department managers to review and complete assigned reports.

ESSENTIAL DUTIES and RESPONSIBILITIES :

The duties and responsibilities listed below reflect the general details necessary to describe the essential functions of the position and shall not be construed as the only duties that may be assigned for the position.

% of Total Time

1.Manage assigned operational components of departmental processes. Research and resolve errors with appropriate internal and external staff. Manage and utilize eligibility reports and systems to support workflow and error resolution. 20%

2.Assist in monitoring for internal and TPA compliance with contractual and regulatory requirements and assist in the preparation and tracking of regulatory audits. Track submission deadlines for various reports. 20%

3.Verify other insurance and document in all required systems 20%

4.Collaborate with Operations Specialist counterparts and serve as a vital component of the operations department team; Create new and utilize existing job aid documents to support consistent work; Provide backup coverage as needed. 10%

5. Monitor and track completion of data requests, reports, and projects; Professionally document all work in appropriate systems; ensure all requests are responded to in a timely and complete manner. 10%

6.Ensure efficient and complete issue resolution by building and maintaining positive, professional relationships with TPAs and internal SCHA departments and through persistent, professional, clear communication. 10%

7. Support operations managers and others with key initiatives and projects as assigned. 5%

8.Other duties as assigned. 5%

QUALIFICATION REQUIREMENT

An individual in this position must be able to successfully perform the essential duties and responsibilities listed above. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

LANGUAGE SKILLS

Must be able to read and write in English.

MATHMATICAL SKILLS

Basic mathematical skills required.

ACCURACY

High attention to detail is required to fulfill the requirements of this position. Processes must be followed accurately to achieve compliance. The impact of errors or negligence could cause significant loss or waste of time. Errors could also have a significant effect on members’ ability to access services or relationships with business partners.

REASONING ABILITY

Must understand cause and effect relationships and be able to draw conclusions from data, regulatory requirements, and past practice; Requires the use of judgment to plan, perform and make decisions within established policy and procedures.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or listen. The employee frequently is required to sit, sometimes for extended periods of time. The employee is occasionally required to stand, walk, kneel; use hands to finger, handle, or feel objects, tools, or controls; and reach with hands and arms.

The employee must rarely lift and / or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually low to moderate.

TRAVEL REQUIREMENTS

This position will rarely travel to out-of-town meetings.

CONTACTS / RELATIONSHIPS

Maintains satisfactory relationships with several external agencies, including Department of Human Services (DHS), Centers for Medicare and Medicaid Services (CMS), TPAs and several internal departments; May include collaboration in implementing established policies and procedures.

FINANCIAL IMPACT

Errors or failure to meet deadlines could result in corrective action or notice of noncompliance.