What are the responsibilities and job description for the Clinical Operations Specialist position at GEHA, Inc.?
Summary
Performs routine administrative workflow tasks that support functions of Clinical Operations. Engages and educates members and providers about GEHA benefits and programs. Identifies cases for internal and external Clinical programs.
Duties
- Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
- Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
- Determines simple cases that require review by Medical Director, Pharmacist or nurse.
- Interprets medical review results to determine compliance with contract provisions.
- Reports suspicions of compliance, clinical, quality, and regulation concerns
- Identifies cases for care and cost management
- Recommend benefit allowances in alignment with contract liabilities
- Actively engages in communication and response with internal and external customers regarding care management, products, and services
- Directs processing of contractual benefits after investigation is complete
- Escalates complex cases to senior team member.
