Claims Operations Specialist

Mar 13 2023
Category: Healthcare
Job Description

Job Summary

**Hybrid Work Environment - Must reside in Hawaii **

The Claims Operation Specialist tracks, analyzes, and resolves claims and claims related system issues while working collaboratively with our vendor to streamline operational processes. In this role, the Specialist will monitor vendor adherence to Service Level agreements, tracking issues and works with multiple areas to ensure HMSA meets all claim goals and objectives.


Minimum Qualifications

  1. Bachelor's degree and three (3) years of related work experience; or equivalent combination of education and work experience
  2. Intermediate level knowledge of Microsoft Office applications. Including but not limited to Word, Outlook, Excel, and Power Point.


Duties and Responsibilities

  1. Assists with collecting, analyzing, and utilizing data and feedback related to Claims to identify opportunities to improve the relationship between the business and the other entity. This will include direct communication and participation with the Vendor Management Office (VMO) and Transformation Management Office (TMO). Compile reports about incidents, events, and updates regarding claims processing issues and conflicts
    • Gathers, reviews, and analyzes information to identify trends, issues, and potential problems and solutions related to development and implementation, including but not limited to new products or services, contract deliverables, enhancements to add functionality and/or redesigns of systems, both manual and automated, to improve efficiency, financial models of costing and pricing. This includes reviewing and validating new implementations.
    • Initiates in the development of strategies and tactics based on logical assumptions and facts considering resources, constraints, and HMSA values. Provides critical assessments of information and data about current trends and issues and actively and openly shares with appropriate parties to encourage collaboration for improvement and change. Translates analysis into solutions and/or options for consideration of specific HMSA actions, including business process improvements.
    • Initiate change and evaluate impact.
    • Conducts ongoing research and analysis to assess changing needs of our industry.
    • Provides quality, objective, and professional analysis.
  2. Assists in communicating with vendor and internal stakeholders to quickly and accurately obtain or provide information regarding claims processing updates:
    • Works directly with cross-departmental team members to complete tasks and provide status updates. Works with HMSA departments and external partners to monitor, collect, communicate, and distribute information. 
    • Communicates analysis, assessments, recommendations and completed work product through professional written and verbal reports and presentations. Conducts presentations to all levels of the organization (unit meetings, department meetings, management meetings, etc.) and our vendor partner to ensure reporting of quality outcomes are consistent and understood.
  3. Communicate process changes to vendor to stay current with government and commercial health plans, agencies, and other entity's guidelines
    • Engages and collaborates with staff and subject matter experts with the planning and implementation of project and sub project work efforts. Supplies or advises in the development of requirements, reports, budgets, and other analysis, and help solve operational issues and roadblocks.
  4. Assists with organizing, maintaining, and keeping readily accessible, all references, documents, policies, and procedures related to claims to ensure correct application of contract benefits between HMSA and Managed Service Provider(s)
    • Analyze and interpret business documents such as HMSA's Medical Policy Manual, plan certificates and Guide to Benefits, statistical data, product development memos and documents published by Blue Cross and Blue Shield Association related to compliance; the literature from Federal and/or state governments pertinent to the business (i.e. Federal Register, CMS guidelines, Hawaii Revised Statutes (H.R.S).
    • Ensures all appropriate processes are followed and documentation is completed as required by acting as quality control checkpoint verifying standards are adhered to.
  5. Proactively solve conflicts and address issues that could occur between HMSA, customers, and service providers
  6. Maintain knowledge of current health plan related to claims and Association requirements
  7. Perform all other miscellaneous responsibilities and duties as assigned or directed.

**For more information and to apply, please visit**



Equal Opportunity Employer - Minorities/Women/Protected Veterans/Disabled