Claims Research and Testing Specialist I

Mar 13 2023
Category: Healthcare
Job Description

Job Summary

Based on assignment and under minimal direction of management, responsible for applying business knowledge to review and research low complexity inquiries received from both internal and external customers. You will be responsible for claims validation and testing to support system upgrades, enhancements, and fixes to existing functionality. You will perform a variety of multi-faceted tasks to include identification of issues and data collection, analysis and interpretation, and documentation to report to Configuration and/or IS. You will be assigned as the lead and coordinate business projects of low complexity.


Minimum Qualifications

  1. Associate's (AA) degree and three (3) years of work experience; or equivalent combination of education and work experience.
  2. Basic working knowledge of Microsoft Office applications including but not limited to Word, Outlook/Email, Excel, and PowerPoint.
  3. Demonstrated knowledge of problem solving, analytical and critical thinking.
  4. Effective written and verbal communication skills
  5. Experience in effectively presenting information to all staff levels which includes management and vendors.
  6. Demonstrated knowledge in issues identification and data collection, analysis, and interpretation.
  7. Demonstrated knowledge of basic mathematical skills.

Duties and Responsibilities

Industry Research and Analysis and Process Improvement:
  • 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.
  • Develops forward thinking, data driven recommendations and strategies that align with business objectives and based on logical assumptions and facts considering resources, constraints, and HMSA values. Delivers critical pieces of analysis and research to drive new insights 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.
  • Initiates change and evaluates impact.
  • Conducts ongoing research and analysis to assess changing needs.
Training and Development:
  • Coordinates implementation within department, including but not limited to development of processing and procedure documentation and training materials as required.
Guiding Project Team and Operational Units:
  • Engages and collaborates with project 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.
Cross-Functional Integration and Communication:
  • Engages closely with cross-departmental team members to complete tasks and provide status updates. Works with the project team, 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 effectively and cross-functionally. Conducts presentations to all levels of the organization (unit meetings, department meetings, management meetings, etc.) to ensure reporting of quality outcomes are consistent and understood.
  • Ensures cross-functional coordination and alignment.
  • May be required to lead and/or coordinate the testing activities which may include gathering and generating test data, identifying test scenarios, status reporting, escalating issues, and performing validation and approval of testing results.
  • Ensures all appropriate processes are followed and documentation is completed as required by acting as quality control checkpoint verifying standards are adhered to.
Other duties as assigned:
  • Performs all other miscellaneous responsibilities and duties as assigned or directed.


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