Care Operations Specialist

About this Role 

The Care Operations Specialist is responsible for the operational aspects of our SurgeryCare solution, ensuring the delivery of exceptional surgery care experiences to our members. In this role, you will leverage your coding expertise to ensure proper case placement in accordance with plan rules and requirements, as well as review post-service claims coding for accuracy, medical necessity, and appropriateness of care. You will serve as a key liaison between our externally facing Care Support Services team and our internal clinical specialists, billing associates, and client and provider relationship managers. Effective communication and collaboration will be critical in managing operational processes and resolving escalations, as well as implementing strategies to improve the quality, effectiveness, and cost-efficiency of our care program. The ideal candidate is excited to roll up their sleeves to dive into details to ensure operational excellence and member satisfaction, as well as serve as a strategic operator and business partner for internal stakeholders across the organization.    

What you'll do  

• Execute day-to-day internal operations of our SurgeryCare product, ensuring seamless member case placement through post-service claims collection and review  
• Collaborate closely with our Care Support Services team to efficiently manage case placement workload, ensuring timely, accurate, and compliant completion of deliverables in line with company and plan policies and procedures 
• Accurately assign CPT codes to patient cases, ensuring proper coding for diagnosis, procedures, and treatments  
• Review post-service claims coding for accuracy, medical necessity and appropriateness of care to minimize billing issues, discrepancies, and delays  
• Communicate effectively with internal operations and management teams to identify and resolve issues, escalations, and delays   
• Develop and implement coding policies, guidelines, and standard operating procedures (SOPs) that comply with legal, ethical, and regulatory requirements (e.g., HIPAA, CMS guidelines)  

What we’re looking for  

• Bachelor’s degree in healthcare or a related field  
• 5+ years related work experience in medical coding, healthcare operations, or revenue cycle management, experience with episodic bundles preferred  
• Active medical coding certification required - Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), or equivalent  
• Deep understanding of medical coding - CPTs, HCPCs, DRGs, ICD-10, etc.  
• Experience with medical billing and claims auditing, as well as working with providers and carriers/TPAs  
• Comfortable working independently and as part of a team, with minimal direct supervision  
• Results-oriented – experience achieving daily metrics and adhering to internal turnaround times  
• Excellent interpersonal and communication skills; willingness to speak up, ask questions, or request clarity when something is unclear  
• Highly organized and detail-oriented; follows standard policies and procedures, but can adapt and problem-solve through non-standard situations or escalate when appropriate    
• Comfortable in a fast-paced and evolving organization with a willingness to be flexible and support occasional after-hours work to address urgent operational issues