IntePros
Claims Operations Specialist (Philadelphia)
IntePros, Philadelphia, Pennsylvania, United States, 19117
The Claims Operations Specialist serves as a key liaison between the business and multiple internal departments, ensuring accurate benefit configuration and timely resolution of benefit-related inquiries. This role supports all lines of business and market segments, including Fully Insured and Self-Funded plans, and plays a critical role in maintaining benefit accuracy, operational alignment, and customer satisfaction.
Key Responsibilities Act as the primary point of contact for benefit-related tickets submitted by Customer Service, Operations, Claims, Sales, Member Appeals, and Executive teams. Review, triage, and manage incidents across all lines of business and market segments, ensuring resolution within established internal SLAs. Conduct in-depth research across multiple systems to validate client, product, and benefit setup. Utilize core applications such as FOS, CSIW, Health Rules Payor, and Product Configurator to investigate and resolve benefit discrepancies. Analyze benefit rules and configurations to identify root causes and recommend corrective actions. Prepare clear, accurate, and professional written responses with supporting documentation for key, high-visibility, and executive-level inquiries. Facilitate cross-functional discussions to align stakeholders on benefit rules, configuration, and interpretation. Ensure consistent understanding and application of benefit logic across departments.
Qualifications Bachelors degree or equivalent relevant experience. 35 years of related professional experience. 4+ years of health insurance claims processing experience. Strong analytical and problem-solving skills with the ability to interpret complex benefit structures. Proven ability to communicate complex concepts clearly to both technical and non-technical audiences. Proficiency in Microsoft Office applications.
Key Responsibilities Act as the primary point of contact for benefit-related tickets submitted by Customer Service, Operations, Claims, Sales, Member Appeals, and Executive teams. Review, triage, and manage incidents across all lines of business and market segments, ensuring resolution within established internal SLAs. Conduct in-depth research across multiple systems to validate client, product, and benefit setup. Utilize core applications such as FOS, CSIW, Health Rules Payor, and Product Configurator to investigate and resolve benefit discrepancies. Analyze benefit rules and configurations to identify root causes and recommend corrective actions. Prepare clear, accurate, and professional written responses with supporting documentation for key, high-visibility, and executive-level inquiries. Facilitate cross-functional discussions to align stakeholders on benefit rules, configuration, and interpretation. Ensure consistent understanding and application of benefit logic across departments.
Qualifications Bachelors degree or equivalent relevant experience. 35 years of related professional experience. 4+ years of health insurance claims processing experience. Strong analytical and problem-solving skills with the ability to interpret complex benefit structures. Proven ability to communicate complex concepts clearly to both technical and non-technical audiences. Proficiency in Microsoft Office applications.