Operations Specialist

Overview

• Provide operational support by identifying and resolving complex system, process, and workflow issues, ensuring efficiency and compliance.
• Act as a subject matter expert for inquiries, audits, and projects, offering guidance and first-level escalation support.
• Perform departmental reporting, tracking, and data analysis to support decision-making and improve processes.
• Conduct quality reviews to ensure accuracy and enhance customer interactions, recommending training as necessary.
• Process various transactions, including claims, adjustments, and correspondence, ensuring compliance and accuracy.
• Communicate compliance needs to management and make outreach calls to members to encourage program participation.
• Educate and guide members in health program participation to drive positive health outcomes.
• Support clinical staff through referrals, documentation, and mailbox management.

Key Responsibilities & Duties

• Identify and document recurring or complex issues, recommending solutions to improve workflows and processes.
• Serve as a subject matter expert for audits, inquiries, and projects, providing detailed support and coaching.
• Perform data analysis and reporting to track departmental performance and identify improvement opportunities.
• Conduct quality reviews to ensure service accuracy and recommend training for performance enhancement.
• Process transactions including claims and correspondence, ensuring compliance with policies and procedures.
• Communicate compliance requirements to management and perform outreach to engage members in health programs.
• Coordinate mailings and educational materials to members, supporting health program participation.
• Assist in updating standard operating procedures and handling complex eligibility and documentation issues.

Job Requirements

• High school diploma or GED required; additional certifications in operations preferred.
• Minimum of 3 years of experience in a related field; 5 years preferred.
• Proficiency in data analysis, reporting, and workflow optimization tools.
• Strong knowledge of compliance standards and ability to communicate requirements effectively.
• Experience in customer service and member engagement strategies.
• Ability to process transactions accurately and handle complex documentation issues.
• Excellent communication skills for outreach and education purposes.
• Familiarity with health program coordination and clinical staff support.