Claims Reimbursement Analyst II (Health Plan Claims & Facets Experience)

CareSource • Ohio WFH, OH

4d • $62,700 - $100,400

About The Position

The Claims Reimbursement Analyst II performs reimbursement analysis to support accurate claims payment, contract compliance, and operational efficiency. The role reviews reimbursement outcomes, identifies payment variances, and supports configuration, testing, and process improvement.

The analyst develops and maintains reimbursement guidelines for assigned CareSource products and collaborates with product owners and cross-functional teams to align processes with organizational strategy, provider contracts, fee schedules, reimbursement methodologies, and industry standards. The position supports benefit interpretation and conducts legislative, regulatory, reimbursement-material, and internal-control reviews.

Responsibilities also include analyzing payment data and implementation results, investigating root causes, recommending corrective actions, and supporting issue resolution. The analyst prepares and executes user acceptance testing, validates configuration and reimbursement logic, conducts postproduction validation, and documents results. The role uses reporting, query, automation, AI-enabled, and other technology-based tools to improve claims accuracy and identify trends and anomalies; prepares reports and business decision documents; manages risks; supports initiatives and budgets, timelines, and task schedules; communicates status to stakeholders; and provides guidance and training to Claims and Operations.

The position is performed in a general office environment. Sitting or standing for extended periods may be required, and travel is not typically required.

Requirements

• Bachelor's degree in Business, Healthcare Administration, Finance, Analytics, or a related field; equivalent years of relevant work experience may be accepted in lieu of the required education.
• Three years of product management, reimbursement policy creation, or claims experience.
• Two years of experience in healthcare reimbursement, claims analysis, or payment operations.
• Familiarity with the healthcare or managed care field and knowledge of government program products.
• Working knowledge of healthcare reimbursement, claims processing, and provider contracting concepts.
• Strong analytical, critical-thinking, and problem-solving skills, including the ability to evaluate payment data, identify trends and anomalies, determine root causes, and recommend solutions accurately and with attention to detail.
• Ability to translate analytical findings into clear documentation and actionable recommendations.
• Proficiency with claims systems, reporting tools, data analysis applications, and Microsoft Office Suite, including advanced Excel skills.
• Understanding of regression, unit, and user acceptance testing methodologies.
• Strong written and verbal communication skills and ability to build relationships and collaborate across cross-functional teams.
• Ability to work independently and collaboratively in a fast-paced, matrixed environment while managing multiple priorities and meeting project deadlines.
• Customer service mindset with a strong member and provider focus.
• Decision-making and problem-solving skills with a demonstrated ability to execute.

Nice To Haves

• Previous experience working with state and federal regulators or government in a managed care setting.
• Familiarity with payment methodologies and industry pricers such as DRG, APC, SNF, and RBRVS.

Responsibilities

• Develop, implement, and maintain reimbursement guidelines for assigned CareSource products.
• Collaborate with product owners and cross-functional partners to align reimbursement processes with organizational strategy, provider contracts, fee schedules, reimbursement methodologies, and industry standards.
• Support Benefit Interpretation activities using applicable grids, spreadsheets, and technology-based applications.
• Conduct legislative, regulatory, reimbursement material, and internal control reviews.
• Analyze reimbursement outcomes, payment data, and implementation results to identify discrepancies, trends, variances, and anomalies.
• Perform root-cause analysis, document findings and impacts, recommend corrective actions, and support issue resolution and escalation.
• Prepare and execute user acceptance testing; validate configuration and reimbursement logic and outputs; conduct postproduction validation; and document test results.
• Use reporting, query, automation, AI-enabled, and other technology-based tools to improve Claims accuracy, quality, execution, analysis, and issue identification.
• Develop recurring, ad hoc, and required reports and business decision documents for internal stakeholders and external governing bodies.
• Identify and manage risks, implement mitigation strategies, and communicate or escalate concerns to key stakeholders.
• Lead and participate in initiatives and team meetings, establish and execute detailed tasks, and demonstrate knowledge of CareSource products.
• Support established budgets, timelines, milestones, and task schedules, and collaborate with senior leadership on initiative funding, resourcing, and management.
• Support and execute published Claims-related policies and procedures and provide stakeholders with status updates, clarification, and verification.
• Provide guidance, support, and training to Claims and Operations.
• Leverage automation and AI-enabled tools to identify reimbursement trends, anomalies, and improvement opportunities.
• Perform other job-related duties as requested.

Benefits

• May qualify for a bonus tied to company and individual performance.
• Substantial and comprehensive total rewards package supporting employee well-being.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level