About PEAK TPA
Peak TPA is a third-party administrator (TPA) that provides back-office functions for capitated health plans. Back-office functions include but are not limited to claims adjudication, member enrollment and reporting, and financial reporting. Peak TPA's partner company, Mediture/Cognify, has a long history in providing software solutions for managing care coordination for capitated health plans. Both companies (subsidiaries of Tabula Rasa Healthcare Company) work closely together to provide integrated and intuitive products to our health plans.
Peak TPA's goal is to seamlessly handle our client’s back-office functions to allow the plan to financially thrive and grow so they can focus on member care coordination.
Claims Operations Trainer
Summary: The Claims Operations Trainer is a subject matter expert in the various products for which PEAK TPA processes claims, including the system functionality for the various software programs used. This position monitors evolving information as it pertains to adjudicating health care claims for PEAK’s contracted clients, in order to educate claims operations staff about PACE programs, and Medicare Advantage and Medicaid Long Term Care plans (serving Medicaid and Medicare members) about benefit and coverage policies, billing policies and payment procedures, including related intake/delivery systems/applications.
Trains all new Claims Analysts according to guidelines set forth in the training plan, and identify training needs for existing Analysts
- Develops a comprehensive understanding of PEAK’s client’s programs and services for each line of business, including Medicare Advantage Plans, Medicaid Long Term Care plans, and PACE programs
- Builds and maintains an internal network of subject matters from other business areas to ensure workflow processes and dependencies between departments are in place to ensure claims adjudicate accurately and timely
- Coordinates and maintains all claims adjudication processes, procedures and training materials in one central repository for staff to use to process claims accurately and timely
- Analyzes and evaluates processes, procedures and manuals on a regular basis to identify and suggest improvements in communications and training products
- Implements training plans using appropriate learning tools, and implement evaluation tool to ensure training is meeting goals
- Develops comprehensive expertise in multiple systems and related front-end technology, in order to use these systems to resolve client/provider/claims operations staff inquires
- Consults with quality, coding, state and federal compliance and legal staff within Peak as appropriate to ensure billing and payment policies meets or does not conflict with state and federal requirements and/or billing/insurance industry standards
- Participates in and represents the Claims department’s business needs during leadership and client implementation meetings, as requested
- Assists with new client and technology implementation with identifying training needs or documentation of business processes
- Participates in special projects such as processing claims, claim entry, client audits, or ad hoc duties as assigned by Management
- Communicates the values of the organization with all new hires. Ensures that all staff are familiar with the organization’s Fundamentals philosophy
- Communicates clearly and concisely, with sensitivity to the needs of others
- Maintains courteous, helpful and professional behavior on the job
- Establishes and maintains effective working relationships with co-workers
- Follows all Policies and Procedures and HIPAA regulations
- Maintains a safe working environment
- Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
- Participates in any required training sessions/seminars
Travel: Less than 10%. As required to conduct training for remote Claims Analysts.
Knowledge, Skills and Abilities:
- Educational requirements include a High School Diploma or equivalent.
- Two years of prior claims processing experience is required.
- Three years of professional work experience in a Health Plan Management setting, and prior experience training individuals and teams on systems is strongly preferred.
- Technical expertise in and thorough understanding of the principles & approaches to training/instructing adult learners
- Ability to communicate clearly and effectively, orally and in writing
- Ability to understand and translate technical information (technical, policy, coding) into appropriate lay language
- Ability to research an write simple to moderately complex technical documents
- Ability to accurately and appropriately respond to sensitive and/or legal/politically volatile provider issue
- Able to apply understanding of large automated computer systems that interact with the user and process data as an end user and as an instructor of an end user
- Experience in MS Word (document creation, tracking, editing), Excel, PowerPoint and SharePoint
- Demonstrated listening, interviewing, customer service, and coaching skills
- Ability to demonstrate the principles of group dynamics and facilitation
- Ability to work effectively with difficult and/or resistant individuals under high-stress conditions
- Demonstrated conceptual, analytic, and problem-solving skills, including problem definition, observation, information gathering, research, and hypothesizing and testing solutions
- Skilled in data analysis and problem solving using defined methodologies
- Ability to provide an informative and positive training experience on a consistent basis
- Ability to independently follow through on projects
- Ability to communicate professionally, clearly and effectively, verbally and in writing
- Ability to prioritize effectively
- Ability to consistently multi-task
Physical Demands & Requirements:
- Communicates in person and by telephone and email with participants, customers, vendors and staff
- Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
- Remains stationary for extended periods of time
- Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects
- Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
- Frequent, repetitive use of hands/fingers entering information on a keyboard
- Occasional reaching to retrieve shelved items
- This job operates in a professional or home office environment with a conversational noise level.
- No substantial exposure to adverse environmental conditions is expected
- Moderate pressure to meet scheduled appointments and deadlines
Tabula Rasa Healthcare
Why Work Here?TRHC provides patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize medication regimens. We improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. We deliver our solutions through a comprehensive suite of technology-enabled products and services for medication risk management and risk adjustment.
Growing company with casual environment, generous benefits and growth opportunities!