Operations Specialist IV -Durable Medical Equipment

Operations Specialist IV - Durable Medical Equipment

Operational Specialist IV is responsible for performing quality assurance reviews on Durable Medical Equipment (DME) referrals that have been denied based on patient benefits or medical necessity. This role also manages the processing of medical necessity denials, ensuring the inclusion of accurate and coverage-specific denial letter language for Physician Champion review. All activities are to be completed in accordance with compliance standards and established timeliness requirements.

Contributes to strategic business planning and development by guiding others to enact data organization via interviews, surveys, focus groups, and databases and defining initiatives to achieve business objectives and informing key business decisions, independently.

Contributes to project execution and management efforts by owning relationships with stakeholders across functions to ensure the project is successfully executed and project-based changes are implemented, independently.

Contributes to monitoring and improving existing processes by leading and performing routine and complex processes, following defined requirements and accountable for achieving expected results for the customer.

Ensures legal, regulatory, and compliance adherence by ensuring others (e.g., clinicians, staff) are provided with information on new or updated organizational and departmental policies, guidelines, procedures; and performing moderately complex project related work in accordance with established federal, state, and local policies, guidelines, procedures, laws, regulations, collective bargaining agreements, and within established service expectations.

Contributes to efforts to develop policies and procedures by drafting sections of policies pertaining to applicable functions and scope so that they reflect best practice, quality, and adhere to regulatory requirements; and applying strategies to write internal, function-level policies that adhere to departmental, organizational, and industry guidelines, and standards.

Contributes to monitoring and improving existing processes by leading and performing routine and complex processes, following defined requirements and accountable for achieving expected results for our customer; maintaining, optimizing, and transforming moderately complex processes to increase efficiency of systems; recommending and designing research plans that identify new and / or existing business operating models and innovative approaches to solutions support; collecting data to determine the nature and requirements of process related improvements, independently; managing stakeholder engagement and communication throughout projects to ensure teams are aligned to gather information and implement process improvements, independently; and creating documentation to communicate updates, changes, or adjustments to function-wide systems, processes, accreditation, or compliance.

Contributes to project execution and management efforts by owning relationships with stakeholders across functions to ensure the project is successfully executed and project-based changes are implemented, independently; tracking, reporting, and coordinating multiple project activities to ensure expectations are met and risks and issues (e.g., financial forecasting) are identified and escalated, independently; and managing relationships with clients and stakeholders to ensure that all project-related expectations are clarified, understood, documented, and met, independently.

Contributes to strategic business planning and development by guiding others to enact data organization via interviews, surveys, focus groups, and databases and defining initiatives to achieve business objectives and informing key business decisions, independently. Identifying project inputs, requirements, and potential risks and ensuring they are documented in strategic business objectives and outcomes; and collaborating cross-functionally to align on the project scope, and moderately complex project deliverables and timelines.

Determines training by developing training requirements to ensure compliance with regulatory and internal standards independently; preparing and delivering training programs to stakeholders and ensuring relevant training certifications are up to date and valid; and developing moderately complex project-based training curriculum for a wide variety of operations related activities.

Promotes learning in others by proactively providing and / or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional / external stakeholders and customers.

Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers.

Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations.

Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes.

Facilitates team collaboration to support a business outcome.

Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies.

Collaborates cross-functionally and / or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results.

Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines.

Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.

Minimum one (1) year of experience in a leadership role with or without direct reports.

Bachelors Degree in Business / Business Administration, Healthcare / Healthcare Administration, or related field AND Minimum three (3) years of experience in data analytics, healthcare business operations or business process analytics, project management or a directly related field OR Minimum six (6) years of experience in data analytics, healthcare business operations or business process analytics, project management, or a directly related field.

Three (3) years of experience working in a large matrixed organization.

Two (2) years of experience in project management.