Claims Operations Specialist
Location: Remote (EST)
Duration: 12 Months+
It is an operationsfocused specialist role requiring handson claims processing experience, deep understanding of backend claims logic, and the ability to manage operational workflows tied to claims adjustments.
The Claims Operations Specialist will support the Mass Claims Adjustments (MCA) team by executing and managing highvolume claims adjustment activities within the Facets platform. This role requires a strong Facets claims subject matter expert who can analyze, validate, and process mass adjustment requests, perform complex data analysis, and partner with internal stakeholders across markets and operations. Each mass adjustment request is treated as a miniproject, requiring structured coordination, documentation, quality validation, and communication.
The MCA team currently consists of six Operations Specialists, and this posting is for two contractor backfill positions, supporting ongoing operational demand.
Key Responsibilities
Mass Claims Adjustment Execution
- Review and validate incoming requests for mass claim adjustments (typically 50+ affected claims), ensuring completeness, accuracy, and alignment with internal guidelines.
- Treat each adjustment request as a miniproject, managing intake, validation, execution steps, and closure.
- Create and manage templates for adjustments within the Facets UI, including benefit, pricing, and configuration touchpoints as needed.
- Process adjustments through Azure DevOps, ensuring traceability, documentation, and timely updates.
- Perform root cause validation and reconcile claim subsets to verify that the adjustment request aligns with actual claim conditions.
Claims Subject Matter Expertise
- Apply advanced knowledge of Facets claims processing, including benefit applications, pricing tables, accumulators, provider configuration, and backend system behavior.
- Execute claim adjustments manually and systemically with a deep understanding of how downstream systems and configuration impact results.
- Identify potential configuration issues, trends, and systemic defects that contribute to mass adjustment demand.
Data Analysis & Validation
- Analyze large data sets to identify impacted claims, validate request criteria, and ensure accuracy before and after adjustment execution.
- Utilize data tools to confirm that the adjustment logic matches expected claim scenarios and business requirements.
- Produce clear, logically structured summaries outlining root causes, validation results, and historical trends to reduce repetitive requests.
Stakeholder Communication & Collaboration
- Communicate effectively with requesters, markets, operations teams, and leadership to obtain approvals, clarify requirements, and provide postadjustment summaries.
- Explain complex claims scenarios, configuration logic, and adjustment rationales in a clear, businessfriendly way.
- Partner closely with automation teams to identify process improvement and automation opportunities, reducing manual ticket submissions.
Operational Governance & Quality Control
- Ensure all adjustments follow internal standards, quality expectations, and compliance requirements.
- Participate in trend analysis discussions and continuous process improvement initiatives across claims operations.
- Support documentation updates, workflow refinements, and knowledge transfer within the MCA team.
Required Skills & Qualifications
Technical & Functional Expertise
- Must have: Advanced Facets claims processing experience, including claim lifecycle, pricing rules, benefit application logic, and backend workflows.
- Strong understanding of claim adjustment processes and downstream operational impacts.
- Experience validating highvolume claim scenarios and interpreting adjustment logic.
- Familiarity with configuration concepts such as:
- Benefit plan structures
- Pricing/reimbursement tables
- Provider and member configuration
- Edit logic and adjudication rules
Data & Analytical Skills
- Ability to analyze large claims datasets using Excel or similar tools.
- Skilled in validating subsets of claims against request criteria and identifying discrepancies.
- Ability to summarize root causes and trends using datadriven analysis.
Communication & Collaboration
- Strong written and verbal communication skills, able to translate technical claims logic into clear business explanations.
- Experience partnering with operations teams, requesters, markets, or other business units.
- Ability to manage multiple adjustment initiatives simultaneously with attention to detail and accuracy.
Tools & Systems
- Facets (required) deep operational expertise.
- Azure DevOps (preferred) for request tracking and workflow management.
- Microsoft Excel and data validation tools (required).
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