Military & Veteran Health Payment Operations SME
Tria Federal is seeking a Healthcare Claims & Payment Operations Specialist to support healthcare claims administration, payment integrity, and Primary Family Caregiver stipend-payment operations within a federal healthcare program. This role will provide operational oversight, analyze complex claims and payment issues, support quality assurance activities, and identify opportunities to improve payment accuracy, efficiency, and compliance.
The ideal candidate brings extensive experience in healthcare claims operations, payer payment administration, or government healthcare programs, along with the ability to translate program requirements into effective operational processes, controls, and recommendations.
Responsibilities:
Primary Family Caregiver Stipend Payments:
Support accurate and timely processing of stipend payments for Primary Family Caregivers in accordance with approved eligibility information, payment instructions, effective dates, and program-specific calculation requirements.
Validate payment inputs, reconcile scheduled and completed payments, investigate discrepancies, and support authorized payment adjustments and corrections.
Coordinate with caregiver program personnel and financial operations teams to resolve missing, delayed, duplicate, or inaccurate payments while maintaining appropriate supporting documentation.
Develop and maintain monitoring and quality controls to assess payment timeliness, calculation accuracy, unresolved exceptions, and changes impacting payment processing.
Process Improvement, Documentation & Implementation:
Translate payment operations requirements into standard operating procedures (SOPs), process maps, business requirements, training materials, quality controls, and decision-support documentation.
Partner with technology teams to identify and define system enhancements, validate payment-related business rules, develop test scenarios, support user acceptance testing (UAT), and assess operational readiness.
Maintain issue logs, corrective-action plans, decision records, and performance dashboards while communicating operational risks and recommendations to Government leadership.
Ensure sensitive beneficiary, provider, clinical, and financial information is handled in accordance with approved security, privacy, and access procedures.
Education & Experience:
Bachelor's degree in Healthcare Administration, Business Administration, Finance, Accounting, Nursing, Health Information Management, or a related discipline. Education substitutions must align with applicable contract requirements.
Seven or more years of relevant experience in healthcare claims operations, payer payment administration, claims quality assurance, payment integrity, or government healthcare program operations.
Demonstrated experience independently analyzing complex claims or payment issues, developing recommendations, and leading corrective actions or operational improvements.
Claims & Payment Expertise:
Hands-on experience across the healthcare claims lifecycle, including intake, validation, adjudication support, payment processing, reconciliation, denials or rejections, and dispute resolution.
Ability to distinguish between eligibility, authorization, clinical review, coverage, reimbursement, and payment-processing issues and engage appropriate stakeholders to resolve them.
Experience interpreting program requirements and translating them into operational procedures, review criteria, and documented business rules.
Experience evaluating payment accuracy, processing timeliness, backlogs, exceptions, and internal controls using operational and financial data.
Consulting & Delivery:
Experience supporting a federal healthcare program, government payer, health plan, or third-party administrator (TPA) environment.
Strong written communication and stakeholder engagement skills, including the ability to develop executive briefings, case summaries, SOPs, and corrective-action plans.
Proficiency with Microsoft Office applications, including Excel, Word, PowerPoint, and Teams, as well as comparable reporting and workflow-management tools.
Ability to meet applicable Government suitability, background investigation, and information-access requirements.