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:

CareSource 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):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.