Job Summary:
The Claims Management Analyst III is responsible for leading eBusiness initiatives and coordination of activities across multiple functional areas.
Essential Functions:
- Manage the EDI (Electronic Data Interchange) trading partners and network of clearinghouses to ensure accurate and timely exchange of information
- Works closely with Vendor Management to improve and maintain the trading partner agreement with the trading partners. This includes cost reduction and adding services
- Develop and maintain a partnership with the trading partner account representatives
- Manage trading partner performance, establish and monitor service level agreements, regulatory requirements, and contractual metrics
- Provide Subject Matter Expertise (SME) to all departments regarding eBusiness specific EDI transactions
- Build, sustain and leverage relationships to constantly allow for continuous improvement of the EDI business process
- Responsible for eBusiness EDI requirements that support regulatory, compliance, and business needs And eBusiness EDI regulatory reporting
- Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
- Review and analyze the effectiveness and efficiency of existing processes and systems, and participate in development of solutions to improve or further leverage these functions
- Participate in the process of estimating initiative budgets as well as developing business cases and tracking the benefits
- Understand business strategy, define and lead eBusiness initiatives such as working with IT and others internal departments to automate functions
- Understand the process to receive claims, claims rejections and denial processes, claims payment methodologies, adjudication processing, and Encounters to enable synergies among It and business groups
- Contribute to and/or develop user stories or provide user story guidance for sprint planning
- Develop, document and perform testing and validation as needed
- Develop and maintain an in-depth knowledge of the company’s business and regulatory environments
- Identify issues, risks, and mitigation opportunities
- Perform any other job duties as requested
Education and Experience:
- Bachelor’s degree or equivalent years of relevant work experience is required
- Minimum of five (5) years of health care operations experience in insurance, managed care, or related industry is required
Competencies, Knowledge and Skills:
- Advanced knowledge of healthcare EDI files (837, 277CA, 999, 270/271, 276/277, etc.)
- Advanced computer skills
- Demonstrated exceptional communication (verbal and written) and high level of professionalism
- Data analysis and trending skills to include query writing Knowledge of Claims IT processes and systems
- Working knowledge of managed care and health claims processing
- Ability to effectively interact with all levels of management within the organization and across multiple organizational layers
- Demonstrates excellent analysis, collaboration skills, facilitation and presentation skills
- Strong interpersonal, leadership and relationship building skills
- Decision making and problem solving skills
- Ability to work independently and within a team environment
- Time management skills; capable of multi-tasking and prioritizing work
- Attention to detail
- Effective decision making / problem solving skills
- Critical thinking and listening skills
Licensure and Certification:
- None
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$70,800.00 - $113,200.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
SalaryOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
Top Skills
What We Do
Health Care with Heart. It is more than a tagline; it’s how we do business. CareSource has been providing life-changing health care to people and communities for nearly 30 years and we will continue to be a transformative force in the industry by placing people over profits.
CareSource is and will always be members first. Even as we grow, we remember the reason we are here – to make a difference in our members’ lives by improving their health and well-being. Today, CareSource offers a lifetime of health coverage to nearly 2 million members through plan offerings including Marketplace, Medicare Advantage and Medicaid. With our team of 4,000 employees located across the country, we continue to clear a path to better life for our members. Visit the "Life" section to see how we are living our mission in the states we serve.
CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law. If you’d like more information about your EEO rights as an applicant under the law, please click here: https://www.eeoc.gov/employers/upload/poster_screen_reader_optimized.pdf and here: https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_EEO_Supplement_Final_JRF_QA_508c.pdf
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