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Claims Operation Specialist

Commonwealth Care Alliance Boston, MA
  • Posted: over a month ago
  • Full-Time
Job Description

The Claims Operation Specialist supports the CCA Payment Integrity/Claims team by aiding in the review claims and payment integrity issues as they relate to provider escalations, data mining/reporting, identification of claims system configuration issues, and other associated requests.


The responsibilities of Claims Operation Specialist role are primarily to support the Payment Integrity/Claims team in the resolution of provider escalations by analyzing and reviewing medical claims, working to resolve post-service appeal requests, and other responsibilities as needed. This role will partner with various departments within CCA, including Clinical/Utilization Management, Contracting, and Provider Relations, to ensure timely resolution of issues, identification of trends, root cause analysis, which may include researching various claims components, and includes corresponding with CCA providers. The role will report to the Manager of Claims and will support various operational functions.


This position will ensure compliance with CCA’s EOHHS contracts for covered benefits, claims processing policies and procedures, and contract terms. This position provides expertise in claims processing by reviewing, researching, investigating, resolving all aspects of claims including identification of over/under payments, variances from contract to claims processing results, testing claims system configuration updates, and more. The position is responsible for documenting findings and providing full resolution to business in a timely fashion. The person in this role must possess a high level of expertise with Medicare/Medicaid medical claims processing/adjudication processes, fee schedules, contract terms, utilization management, coverage and reimbursement policies and claims processing standard operating procedures.

Responsibilities include:

  • Identifying efficiencies and reducing manual processes
  • Review and development of payment integrity/claims policies and procedures and standard operating procedures
  • Fostering a high-performance structure between CCA and its claims processing vendor.
  • Conduct investigations following provider escalation regarding payment/processing of medical claims, including provider outreach, review of medical claims and provider EOPs. May include coordination with partner departments to expedite resolution.
  • Provide updates on progress of escalation resolution, including recommendations for further actions and/or resolutions.
  • Prepare summaries and/or detailed reports on escalation trends, findings, etc.
  • Perform data mining and analysis to detect errors and outliers in claims. Assess and communicate financial impact of the errors identified to CCA management (if applicable).
  • Develop new queries and reports to detect potential cost-savings as it relates to waste, abuse, and fraud.
  • Respond to all telephonic, email, fax, mail inquiries regarding claim inquiries.
  • Coordinate with claims vendor to retract, adjust, and/or pay claims when necessary.
  • Coordinate recoveries of dollars per federal regulations directly with other insurers for services unable to be recovered with the provider (Coordination of Benefits, Good Cause Clause, Third Party Liability)
  • Document work performed and escalation results based on pre-determined standards and guidelines.
  • May be assigned to work on reporting, special projects, and business initiatives as necessary.
  • Adhere to all applicable compliance requirements and the Code of Conduct.

  • Bachelor's Degree or equivalent experience.
  • Minimum 4+ years managed care or medical insurance experience.
  • 2+ years’ experience in a medical claims, customer services, or provider support role.
  • Strong negotiation, de-escalation, and conflict resolution skills. 
  • In-depth experience and knowledge of industry standard medical claims processing
  • Knowledge of CPT/HCPCS and ICD-10 codes is required
  • Strong knowledge of Medicare/Medicaid claims protocols
  • Candidate must be able to prioritize work and use independent judgment
  • Excellent verbal and written communications skills are essential
  • Strong analytical skills
  • Strong customer facing skills
  • Intermediate MS Excel experience
    • This includes the ability to create and build spreadsheets with pivot tables, formulas, and advanced function capabilities
  • Intermediate knowledge of Microsoft PowerPoint and Microsoft Word
    • This includes the ability to create slide presentations


Commonwealth Care Alliance

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