Business Operations Specialist

Responsibilities

• Responsible for the maintenance, revision, and implementation of Policies and Procedures to ensure compliance with applicable regulatory standards and contractual obligations.
• Prepare, develop and make recommendations by analyzing reports and operational data to support operational improvements and enforcement of established standards.
• Work collaboratively with overall operations management team to develop operational efficiencies, maintain contractual requirements, and ensure compliance of core operations with various rules and regulations.
• Conduct continual research of new and revised accreditation and regulatory standards applicable to CMS in collaboration with external PSERS vendors.
• Maintain a database of regulatory requirements applicable to PSERS processes.
• Maintain the ongoing maintenance and revision of PSERS Division and Utilization Management Policy.
• Act as the Department Liaison for maintenance of required Regulatory Filings/Reports and CMS inquiries.
• Collect, analyze and report on key metrics, identify trends, barriers, perform root cause analysis when applicable, and provide objective recommendations.
• Recommend process improvements for everyday operating procedures.
• Assist with the ongoing analysis of the PSERS Program to identify opportunities for process improvement, reengineer processes to improve efficiencies, and ensure compliance.
• Provide expertise in regulatory/accreditation issues/inquiries for all PSERS functional areas.
• Maintain a positive and educational approach when interacting with both internal and external customers to explain the Regulatory Compliance Program needs.
• Assist with the orientation of personnel and contribute to ongoing networking of expertise with colleagues.
• Compile information from data sources and provide backup support for system administration, including collecting, analyzing, and summarizing information.
• Collaborate with management to identify trends and issues for short-term and long-term resolution, leveraging people, process, technology, and updated communications/tools.
• Promptly review Medicare Part A/D changes and determine impact to PSERS operations.
• Share information with the operational team, assess impact, and implement changes as needed to ensure proper tools and educational information is shared with frontline team members or impacted individuals.
• Review eligibility and customer service audits, as well as Medicare program audits, to determine steps needed to correct issues, report, and respond to CMS.

Requirements

• High School Diploma
• Minimum three to five years’ experience with insurance operations, business or technical experience specific to claims, customer service or enrollment
• Ability to work in a fast-paced, customer service & production driven environment
• Excellent verbal and written communication skills
• Ability to work effectively with employees/members, providers, and differing levels of co-workers and all levels of staff
• Ability to use common sense understanding to carry out instructions furnished in oral, written or diagram form
• Flexible; open to continued process improvement
• Self-directed individual who works well with minimal supervision
• Good leadership, organizational and interpersonal skills
• Ability to give direction and provide feedback
• Demonstrated critical thinking skills
• Ability to effectively deal with problems in varying situations and reach resolution
• Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Excel/Word
• Previous working knowledge of Medicare and CMS regulations.
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