South Country Health Alliance has an immediate need for an Operations Specialist at our Medford Office!

The Operations Specialist serves as the primary point of contact for member eligibility, including eligibility related benefits and claims issue resolution within the organization and with outside partners; Research and resolve operational issues and serve as the day-to-day point of contact for internal and external partners. Work closely with operations department managers to review and complete assigned reports.

Requirements include Associate or bachelor’s degree in health care administration, business administration, or related industry and one year experience in healthcare administration, pharmacy benefit management, or related industry required. Three years experience in above industries considered in lieu of degree. Basic knowledge of State and Federal programs (Medical Assistance and Medicare Part D) preferred.

South Country offers a full range of comprehensive benefits such as medical, dental, vision, and more as well as competitive pay.

This position is a grade 5 and salary ranges from a minimum of $23.74 to $33.10/ hour, based on experience.

POSITION DESCRIPTION (Non-Exempt)
Position Title: Operations Specialist

Dept: Operations

Reports To: Director of Operations

Date: November 2024

Skill Set: Possess critical thinking skills, problem solving, attention to detail, ability to
understand complex processes; Ability to represent South Country Health Alliance to its Third
Party Administrators (TPAs) and regulatory entities in a professional manner; Possess excellent
interpersonal, verbal and written skills; Ability to multi-task; Excellent organization,
prioritization, and time management skills; Proficient in Microsoft Office Suite, to include ability
to work with a variety of file formats.

Education/Experience: Associate or bachelor’s degree in health care administration,
business administration, or related industry and one year experience in healthcare
administration, pharmacy benefit management, or related industry required. Three years
experience in above industries considered in lieu of degree. Basic knowledge of State and
Federal programs (Medical Assistance and Medicare Part D) preferred.

Primary Function
Serve as the primary point of contact for member eligibility, including eligibility related benefits and claims issue resolution within the organization and with outside partners; Research and resolve operational issues and serve as the day-to-day point of contact for internal and external partners. Work closely with operations department managers to review and complete assigned reports.

Essential Accountabilities
1. Manage assigned operational components of the eligibility and enrollment process. Research and resolve eligibility errors with appropriate internal and external staff. Manage and utilize eligibility reports and systems to support workflow and error resolution.
2. Research and resolve member issues with appropriate internal and external staff.
3. Build and maintain positive and professional relationships with TPAs and internal SCHA departments to facilitate effective member issue resolution.
4. Ensure efficient and complete issue resolution through persistent, professional, clear communication.
5. Develop understanding of South Country products and services in support of day to day responsibilities.
6. Support Operations Managers with key initiatives and projects as assigned.
7. Professionally document all work in appropriate systems; ensure all requests are responded to in a timely and complete manner.
8. Become knowledgeable about State and Federal eligibility requirements and regulations in order to ensure compliance.
9. Collaborate with Operations Specialist counterparts and serve as a vital component of the Operations Department Team; Create new and utilize existing job aid documents to support consistent operations specialist work; Provide backup coverage as needed.
10. Develop documents and reports, utilizing systems to identify trends to support departmental programming.
11. Perform other duties as assigned within the scope, responsibility, and requirements of the job.

Qualification Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Language Skills:
Must be able to read and write in English.

Mathematical Skills:
Basic mathematical skills required.

Accuracy:
High attention to detail is required to fulfill the requirements of this position. Processes must be followed accurately in order to achieve compliance. The impact of errors or negligence could cause significant loss or waste of time. Errors could also have a significant effect on member’s ability to access services or relationships with business partners.

Reasoning Ability:
Must understand cause and effect relationships and be able to draw conclusions from data, regulatory requirements, and past practice; Requires the use of judgment to plan, perform and make decisions; problem solving is a greater challenge.

Physical demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to sit, sometimes for extended periods of time. The employee is occasionally required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; and reach with hands and arms.
The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee should encounter no unusual or hazardous conditions. The noise level in the work environment is usually low.

Travel Requirements:
Employee must be able and willing to travel. Average instate travel requirement is 1 day per quarter.

Contacts
Maintains satisfactory relationships with several external agencies, including Department of Human Services (DHS), Centers for Medicare and Medicaid Services (CMS), TPAs and several internal departments; May include collaboration in executing established policies, discussion of ways to reach agreed-upon objectives and securing compliance with approved procedures.

Financial Impact
Limited responsibility, where errors are likely to be detected and corrected before permanent harm is done. This position is responsible for ensuring that SCHA is following contract language as promulgated by governmental agencies. Failure to comply with this contractual language could result in breach of contract resulting in a financial penalty, potential contract cancellation, sanctions and/or corrective action.