Business Operations Specialist

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Luminare Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

Healthcare Insurance

Luminare Health is a leading provider of self-funded health plan administration services with over 50 years of industry experience. The company specializes in offering flexible and innovative solutions for hospitals, health systems, and direct-to-employer initiatives, focusing on administration, cost management, and digital reporting tools. Luminare Health is dedicated to being a reliable partner in managing healthcare costs and supporting strategic growth for its clients. The company emphasizes a member-centered approach to healthcare while delivering significant savings through expert claim analysis and management of high-cost claims.

📋 Description

• 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 overall compliance of core operations is in conformity 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 • Responsible for the ongoing maintenance and revision of PSERS Division and Utilization Management Policy • Acts as the Department Liaison for maintenance of required Regulatory Filings/Reports and CMS Inquiries • Collect, analyze and report on key metrics inclusive of identifying trends, barriers, conducting root cause analysis when applicable and providing objective recommendations • Recommend process improvements for every day operating procedures • Assist with the ongoing analysis of the PSERS Program to identify opportunities for process improvement, reengineers processes to improve efficiencies and to 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 in explaining the Regulatory Compliance Program wants and needs • Assist with the orientation of personnel and positively contribute to the ongoing networking of expertise with colleagues • Compile information via data sources and provide back up support for system administration collecting, analyzing, and summarizing information. • Work collaboratively with management team to work on identified trends and issues for short term and long term resolution, leveraging people, process, technology, and team communications/tools are updated. • Promptly review Medicare Part A/D changes and determine impact to PSERS operations • Share the information with operational team and assess impact, implementing changes as needed, to ensure proper tools and educational information is shared with front line team members or impacted individuals • Review eligibility and customer service audits, as well as Medicare program audits, to assess steps needed to be taken 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.

🏖️ Benefits

• Health and wellness benefits • 401(k) savings plan • Pension plan • Paid time off • Paid parental leave • Disability insurance • Supplemental life insurance • Employee assistance program • Paid holidays • Tuition reimbursement • Other incentives