Offer summary

Qualifications:

Bachelor’s degree or equivalent work experience required., Minimum of two years in a healthcare claims environment is required., Experience with SQL/Access and Facets claims processing is highly preferred., Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10, and HCPCS coding..

Key responsabilities:

Represent claims on cross-functional project work teams and assist with IT ticket management.

Review special projects, identify issue trends, and assist in training claims staff on policies and procedures.

Research and resolve provider claim issues by analyzing system configuration and claims data.

Perform data analysis to support decision-making for the Claims management team.

Job description

Job Summary:

The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects.

Essential Functions:

Represent claims on cross-functional project work teams
Submit, monitor and prioritize IT tickets for the Claims department
Review special projects and identify issue trends and potential resolutions
Assist with Onbase reporting and processes
Develop and draft P&P’s and job aides for Claims
Assist in training claims staff on claims processing policy and procedures
Assist in educating/training Business Partners on claims functions
Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data.
Perform analysis of all claims data in order to provide decision support to Claims management team
Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
If assigned to Research and Resolution team, responsibilities include:
- Represent Claims Department at requested provider calls and visits
- Provide feedback and/or face-to-face interaction with providers for claims research and resolution
- Responsible for research and resolution of claims issues for all assigned provider inquiries and submissions
- Responsible for managing provider issues adhering to Workflow processes and tools (Facets and Onbase)
- Provide input for claims business requirements, testing processes and implementation tasks and plans
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 claims environment is required
SQL/Access experience highly preferred
Facets claims processing experience highly preferred
Automation experience highly 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:

$61,500.00 - $98,400.00

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. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies