Operations Specialist III
CareSource•Dayton, OH
•Onsite
About The Position
The Operations Specialist III provides analytical support and leadership for key Claims-related projects. This role involves regulatory reporting, claims review, identifying payment integrity issues, and serving as a Subject Matter Expert (SME) for various projects and meetings. The specialist will also contribute to policy development, lead claims initiatives, and assist in implementing new business processes.
Requirements
- 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
- 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
Nice To Haves
- None
Responsibilities
- 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
Benefits
- Substantial and comprehensive total rewards package
- Bonus tied to company and individual performance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
