Clinical Operations Specialist

GEHA (Government Employees Health Association, Inc., pronounced G.E.H.A.) is a nonprofit member association that provides medical and dental benefits to more than two million federal employees and retirees, military retirees and their families. We celebrate diversity and are committed to creating an inclusive environment for all employees.

GEHA has one mission: To empower federal workers to be healthy and well.

Offering one of the largest medical and dental benefit provider networks available to federal employees in the United States, GEHA empowers health and wellness by meeting its members where they are, when they need care. We serve our members with products they value and a personalized customer experience, sustained by a nimble and efficient organization.

RESPONSIBILITIES

• Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
• Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
• Determines simple cases that require review by Medical Director, Pharmacist or nurse.
• Interprets medical review results to determine compliance with contract provisions.
• Identifies cases for care and cost management
• Actively engages in communication and response with internal and external customers regarding care management, products, and services
• Directs processing of contractual benefits after investigation is complete
• Escalates complex cases to senior team member.
• May place calls to members and communicates barriers and opportunities identified through member outreach calls
• Ensure compliance for all quality audits and maintain all data and process controls and reports suspicions of compliance, clinical, quality, and regulation concerns
• Educates members on applicable plan benefits and service information
• May be tasked to initiate process to request and evaluate member compliance reports for HEDIS measures, including evaluating improvement opportunities.
• May be tasked with completing HEDIS quality specific projects assisting members in scheduling primary care appointments

REQUIREMENTS

• Requires two years (60 credit hours) of college or 2 years of healthcare experience, additional years of qualifying work experience may be considered in lieu of formal education.
• Requires intermediate proficiency with technology applications and systems.
• Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams.
• Requires effective written and verbal communication skills.
• Must be able to work Monday - Friday 9:00am - 6:00pm.
• Must reside in the Kansas City Metro

PREFERRED

• Preferred knowledge of HEDIS and CAHPS

Work-at-home requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

How we value you

• Competitive pay/salary ranges
• Incentive plan
• Health/Vision/Dental benefits effective day one
• 401(k) retirement plan: company match - dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
• Robust employee well-being program
• Paid Time Off
• Personal Community Enrichment Time
• Company-provided Basic Life and AD&D
• Company-provided Short-Term & Long-Term Disability
• Tuition Assistance Program

Please note that the salary information is a general guideline only. GEHA considers factors such as (but not limited to) scope and responsibilities of the position, candidate's work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.

GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees. Our diversity drives innovation deepens connections and strengthens our organization.

GEHA is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.