Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care. G.E.H.A has one mission: To empower federal workers to be healthy and well. Role overview: - Performs routine administrative workflow tasks that support functions of Clinical Operations. - Engages and educates members and providers about G.E.H.A benefits and programs. - Identifies cases for internal and external Clinical programs. Role Responsibilities: - Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need. - Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care. - Determines simple cases that require review by Medical Director, Pharmacist or nurse. - Interprets medical review results to determine compliance with contract provisions. - Reports suspicions of compliance, clinical, quality, and regulation concerns. - Identifies cases for care and cost management. - Recommend benefit allowances in alignment with contract liabilities. - Actively engages in communication and response with internal and external customers regarding care management, products, and services. - Directs processing of contractual benefits after investigation is complete. - Escalates complex cases to senior team member. Requirements: - Requires two years (60 credit hours) of college or 2 years of healthcare experience. Additional years of qualifying work experience may be considered in lieu of formal education. - Requires intermediate proficiency with technology applications and systems. - Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams. - Requires effective written and verbal communication skills. - Must reside in Kansas City Metropolitan area. - Work-at-home requirements: - Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.