Job Summary:
The Operations Regulatory Specialist II provides analytical support and leadership for key internal Operations projects and partners with the Operations departments to ensure all regulatory and compliance deliverables are met. This position will work Tues/Thurs in the Dayton, Ohio office and remote the other days.
Essential Functions:
- Represent operations on cross-functional project work teams
- Submit, monitor and prioritize IT tickets for the operations departments
- Review special projects and identify issue trends and potential resolutions
- Assist with reporting and processes that are regulatory related and tied to state issues deadlines
- Assist with the development, drafting and review of P&P’s and job aides for Operations
- Assist in educating/training Business Partners on operations functions.
- Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
- Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
- Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
- Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include:
- Documentation gathering – i.e. review of Standard Operating Procedure and/or Policy and Procedure to the audit/inquiry requirements
- Audit Universe monitoring and/or creation – collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submission
- Prepare Operations Business Owners for live questions and answers with the state regulators or auditors
- Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
- Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
- Track all Compliance required training on a yearly and new hire basis for Operations
- Assist with all readiness activities in relation to implementation of a new line of business for Operations
- Perform any other job-related instructions, as requested
Education and Experience:
- Bachelor’s degree or equivalent years of relevant work experience required
- Minimum of two (2) years of healthcare operations environment is required
- Regulatory and/or compliance experience is preferred
Competencies, Knowledge and Skills:
- Advanced level experience in Microsoft Word, Excel and PowerPoint
- Data analysis and trending skills
- Demonstrated understanding of claims operations specifically related to managed care
- Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
- Ability to work independently and within a team environment
- Attention to detail
- Familiarity of the healthcare field
- Critical listening and thinking skills
- Negotiation skills/experience
- Strong interpersonal skills
- Proper grammar usage
- Technical writing skills
- Time management skills
- Strong communication skills, both written and verbal
- Customer service orientation
- Decision making/problem solving skills
Licensure and Certification:
- None
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$62,700.00 - $100,400.00CareSource 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
Skills Required
- Bachelor's degree or equivalent years of relevant work experience
- Minimum of two (2) years healthcare operations environment experience
- Regulatory and/or compliance experience
- Advanced level experience in Microsoft Word, Excel and PowerPoint
- Data analysis and trending skills
- Demonstrated understanding of claims operations related to managed care
- Advanced knowledge of coding and billing processes including CPT, ICD-9, ICD-10 and HCPCS
- Ability to work independently and within a team environment
- Attention to detail
- Familiarity with the healthcare field
- Technical writing skills and proper grammar usage
- Strong written and verbal communication skills
- Time management, decision making, problem solving, and customer service orientation
- Negotiation and strong interpersonal skills
CareSource Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CareSource and has not been reviewed or approved by CareSource.
-
Strong & Reliable Incentives — Bonuses are regularly available and serve as a meaningful part of total compensation. Annual performance-based awards are considered a strong component.
-
Leave & Time Off Breadth — PTO starts around four weeks and increases with tenure, complemented by paid holidays and a floating day. Volunteer time expands the available leave options.
-
Affordable Benefits — Health plan options are considered affordable, supported by wellness incentives that can reduce premiums. Coverage breadth includes medical, dental, vision, and cost‑lowering programs.
CareSource Insights
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 Si usted o alguien a quien ayuda tienen preguntas sobre CareSource, tiene derecho a recibir esta información y ayuda en su propio idioma sin costo. Para hablar con un intérprete, Por favor, llame al número de Servicios para Afiliados que figura en su tarjeta de identificación. 如果您或者您在帮助的人对 CareSource 存有疑问，您有权 免费获得以您的语言提供的帮助和信息。 如果您需要与一 位翻译交谈，请拨打您的会员 ID 卡上的会员服务电话号码
