Clinical Operations Spec
Core
Performs routine administrative workflow tasks to support Clinical Operations functions, including claims review, case identification, and member/provider engagement.
Role type
Clinical Operations Specialist (Administrative/Claims Review)
Builds
Internal clinical programs and member benefit delivery
Domain
Healthcare administration and federal employee benefits
Deliverable
Dashboards & analysis | client delivery
Required skills
Claims investigation, medical necessity determination, contract compliance interpretation, care management, case escalation, benefit allowance recommendation, data reporting
Preferred skills
None stated
Technologies
Microsoft Office (Outlook, Excel, Word, Teams), clinical review systems
Responsibilities
Coordinate, review, and investigate claims to determine medical necessity; identify cases for internal and external clinical programs; interpret medical review results for contract compliance; report compliance and quality concerns; recommend benefit allowances; direct processing of contractual benefits after investigation; escalate complex cases to senior team members.
Seniority
Mid-level, hands-on IC