Claims Operations Specialist

Process and manage assigned copay assistance, claims operations, electronic service delivery, and related Jira tickets from intake through resolution Review daily claim reject, quality assurance, and other operational reports; research exceptions; complete approved corrective actions; and escalated issues Research routine claim processing questions and escalations using claim history, member and plan information, system responses, and established procedures Resolve pharmacy-related requests within established service-level agreements Identify whether issues require established procedures, configuration, code changes, vendor intervention, advanced analysis, or escalation Execute assigned claim testing and validation using approved test scripts, record results, identify discrepancies, and escalations Support client readiness and operational change activities through testing, impact review, procedure updates, and documentation confirmation Perform data entry, file review, reconciliation, and recurring claims operations activities Create and maintain procedural documentation, job aids, ticket notes, and knowledge articles Compile and validate routine operational reports and metrics Communicate ticket status, required information, resolution steps, and escalations with internal partners Protect confidential, proprietary, and protected health information Participate in process improvement, root cause reviews, compliance, people and culture, and learning programs Perform other duties as assigned Requirements High school diploma or GED required Associate’s degree in business, healthcare administration, information systems, or a related field preferred 1+ year of experience in claims processing, healthcare operations, pharmacy benefit management, customer service operations, or a related transaction-processing environment preferred Experience researching and resolving work items through a ticketing or case management system preferred Working knowledge of healthcare or pharmacy claims, including basic claim status, reject, reversal, and adjustment concepts, preferred Ability to follow documented procedures, manage multiple work items, meet service-level expectations, and escalated issues Proficiency with Microsoft Windows and Microsoft Office applications, including Excel, Outlook, Word, and PowerPoint, required Experience with Jira or another service management or workflow platform preferred Basic SQL knowledge or experience using reporting/query tools preferred Knowledge of ticket processing, claim research, reject review, issue documentation, escalation, and service-level management Knowledge of data accuracy, reconciliation, test execution, evidence capture, confidentiality, and procedural compliance Concise written documentation, status updates, cross-functional coordination, and professional issue resolution Core Competencies Demonstrates expertise in claims processing and healthcare operations, with a strong focus on issue resolution, procedural compliance, and effective communication. Proficient in using ticketing systems and Microsoft Office applications to manage workflows and documentation. Highest-signal resume keywords Claims Processing Healthcare Operations Jira Ticket Management Data Reconciliation Microsoft Office Proficiency ATS Optimization Keywords Hard Skills Claims Processing Data Entry SQL Knowledge Test Execution Issue Documentation Service-Level Management Quality Assurance Operational Reporting Pharmacy Benefit Management Ticket Processing Soft Skills Concise Written Communication Cross-Functional Coordination Professional Issue Resolution Industry Keywords Healthcare Claims Pharmacy Claims Service-Level Agreements Operational Change Activities Confidentiality Compliance Tools & Technologies Jira Microsoft Windows Microsoft Excel Microsoft Outlook Microsoft Word Microsoft PowerPoint #J-18808-Ljbffr Jobtailor