Karna, LLC

Network Operations

• Play an essential behind-the-scenes role in supporting the Provider Relations team and the NIOSH World Trade Center Health Program.
• Focus on maintaining accurate provider network data, completing timely data entry and updates, analyzing information for trends or inconsistencies, and helping ensure provider records and documentation are complete, organized, and reliable.
• Maintain provider network data across multiple tracking reports, systems, and internal data sources, ensuring records are accurate, complete, and current.
• Perform high-volume data entry, data validation, and record maintenance related to provider demographics, enrollment documentation, contract status, and other network information.
• Review provider data for accuracy, consistency, duplicates, missing information, and potential discrepancies; research issues and coordinate corrections through established processes.
• Prepare, update, and analyze reports to support provider network operations, identify trends, monitor pending items, and assist the team with prioritizing follow-up work.
• Support the secure exchange, tracking, and organized management of provider enrollment and network documentation in accordance with program requirements and internal procedures.
• Assist with incoming internal requests, shared mailbox items, ServiceNow tickets, and escalated operational questions by researching information, updating records, and routing items appropriately.
• Partner with internal stakeholders to support timely resolution of provider data issues, claims-related research, grievances, compliance reviews, and other operational needs.
• Follow standard operating procedures, maintain accurate documentation of work completed, and recommend process improvements that strengthen data integrity and team efficiency.

Network Operations Specialist

Claims Specialist

• Analyze and process a variety of complex medical claims in accordance with program policies and procedures, ensuring accuracy and compliance.
• Analyze claims and adjudicate them according to program guidelines, employing critical thinking to navigate complex scenarios.
• Ensure claims are processed promptly to meet client standards and regulatory requirements, employing effective problem-solving skills to address any barriers.
• Proactively resolve claim discrepancies and issues by collaborating with other departments, utilizing analytical skills to identify root causes and implement solutions.
• Uphold the confidentiality of patient records and company information as per HIPAA regulations.
• Maintain thorough records of claims processed, denied, or requiring further investigation, ensuring transparency and traceability.
• Analyze and report on trends in claim issues or irregularities to management, contributing to process improvement initiatives; Assists Team Leads with reporting.
• Engage in audits and compliance reviews to ensure adherence to internal and external regulations, using critical thinking to evaluate processes.
• Mentors and trains new claims processors as needed.

Network Operations Specialist

Healthcare Claims Processor