Job Summary:
The Operations Specialist III provides analytical support and leadership for key Claims-related projects.
Essential Functions:
- Regulatory reporting such as CMS and Medicaid Prompt Pay
- Serve as high dollar claims reviewer
- Identify payment integrity issues with claims reimbursement methodologies
- Prepare and deliver responses to legal correspondence and state complaints
- Provide Claims Subject Matter Expertise (SME) for cross-functional meetings including operational and new business implementation
- Act as primary Claims Representative and SME for corporate projects
- Act as primary Claims Representative on external audits
- Assist in development of policies and procedures for claims processing, COB, appeals and adjustment functions
- Lead Claims initiatives such as working with IT and others to automate claim functions; improve front end paper claim process; and report development with SIS
- Contribute to and/or develop user stories or provide user story guidance for sprint planning
- Implement new business including the design, testing and delivery of supporting processes to the business
- Perform any other job related instructions, as requested
Education and Experience:
- Bachelor’s degree or equivalent years of relevant work experience required
- Minimum of five (5) years of healthcare claims environment, equivalent managed care, healthcare operations or professional industry experience is required
Competencies, Knowledge and Skills:
- Advanced proficiency level experience in Microsoft Word, Excel and PowerPoint
- Data analysis and trending skills
- Work with accumulators
- 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
- Effective communication skills
- Strategic management skills
- Ability to work independently and within a team environment
- Attention to detail
- Critical listening and thinking skills
- Negotiation skills/experience
- Technical writing skills
- Time management skills
- 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:
$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
Create an Inclusive Environment
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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