Operations Analyst
POSITION SUMMARY: This position is an integral part of the Operational team. In this role, the analyst will assist in various Operational processes including; new client setup, management of client, system configuration, claims resolution, and quality control of client related transactions. This individual will be a key resource to answer inquiries from other areas throughout the company.
Essential Functions:
Client Setup
- Record system transactions to account for any changes in a client’s general and/or benefit information.
- Quality control checks of all system transactions.
- Serves as a resource to the organization regarding processing of client related information and transactions.
- Maintain and process client renewal transactions.
System Configuration
- Research and configure system rules based off client benefit modifications, CDT updates and companywide policy changes.
- Propose new innovative rules to Management that enhance the claim processing system that will help build efficiencies and increase accuracy.
Claims Resolution
- Plans, allocates, and monitors workflow to assure the accurate and timely completion of assignments within established production and inventory standards.
- Assists in the oversight of the processing and adjudication of claims by guiding the activities of the claims analysts; monitors and communicates corporate policies and procedures to assure a high level of accuracy and completeness within established production and inventory standards.
- Researches any unusual payments and refunds; processes the most complex type of claims which involve judgment and interpretation based on precedent, knowledge of the dental terminology, and a thorough understanding of the Corporation’s claims processing policies and procedures.
- Research and resolve potential client overpayments and underpayments.
- Performs the overpayment recovery process to recoup overpayments made to the dentists.
- Interact regularly with Customer Service to answer claim-related questions.
Data Analysis and Reporting
- Becomes knowledgeable with analytical tools and collaborates/recommends new operational reports to Data Analytics team.
Quality Control
- Responsible for the quality of various operations department tasks including rule updates, coordination of benefit processing, ortho claims, internally entered claims pretreatments and client data management.
Testing
- Assists in the evaluation of all system releases to ensure accuracy and completion.
- Participates in pre-release testing with Project Management
Other Duties
- Participates in special projects as required by management.
- Performs other duties as assigned.
Requirements:
- High School Diploma or equivalent; Associates or Bachelor’s degree preferred.
- Excellent communication and organizational skills.
- Attention to detail and accuracy.
- Prior knowledge of database programs preferred.
Entry Level Training Received (If any)
- Extensive training in claim, eligibility, and provider functions as well as workstation training.
Work Environment / Physical Demands:
- Typical office environment
Attendance Requirements:
- 40-hour workweek (M-F) as assigned and additional hours as required