Health Plans Operations Specialist, Appeals

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

The Health Plans Operations Specialist oversees projects and initiatives, conducts internal audits, and provides training to ensure accuracy and compliance. This role involves coordinating with various departments and vendors, implementing projects, and enhancing staff skills through auditing and effective training.

Corporate Overview: University of Utah Health is an integrated academic healthcare system with five hospitals including a level 1 trauma center, eleven community health centers, over 1,600 providers, and a health plan serving over 200,000 members. University of Utah Health is nationally ranked and recognized for our academic research, quality standards and overall patient experience. In addition to our clinical delivery system, we have a School of Medicine, School of Dentistry, College of Nursing, College of Pharmacy, and College of Health providing education and training for over 1,250 providers annually. We have over 2 million patient visits annually and research grants exceeding $350 million. University of Utah Hospitals and Clinics represents our clinical operations for the larger health system.

Essential Functions

• Manage Clinical Operations projects to completion.
• Report on project progress and outcomes.
• Coordinate with external vendors and stakeholders.
• Evaluate progress of Clinical Operations initiatives and adjust as needed.
• Develop and implement Clinical Operations processes.
• Conduct internal audits to assess accuracy and completeness.
• Ensure compliance with internal controls, policies, and regulations.
• Identify areas for improvement and provide recommendations.
• Prepare audit reports and present findings.
• Design and develop training based on identified needs.
• Prepare and maintain educational materials.
• Collaborate with health plan leaders and other departments.
• Analyze data to identify trends and areas for improvement.
• Maintain updated records of educational materials.

Knowledge / Skills / Abilities

• Ability to perform essential job functions.

• Ability to analyze and document complex processes.

• Knowledge of project coordination.

• Computer, organizational, human relations, and communication skills.

Required

• Bachelor's degree, or equivalency.
• Two years of applicable experience.

Preferred

• Billing or Coding Certification through AAPC.
• Knowledge of and experience with Medicaid and Commercial insurance.
• Certification as a Project Management Professional (PMP).
• Advanced Excel Experience (pivot tables, Power Query, macros,VBA,Data Model).
• Trend identification and Root cause analysis.
• Performance metrics (KPIs, SLAs).
• Healthcare operations (preferably Appeals & Grievances, Claims, or Quality).

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.

Listening, Sitting, Speaking