Job Summary:
The Operations Specialist I 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
- Review claim adjustment requests and determine appropriate method of adjustment (MCA, robot, manual)
- 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
- If assigned to Research and Resolution team, responsibilities include:
- 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 ServiceNow)
- 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 one (1) year of healthcare claims environment is required
- Facets claims processing experience highly preferred
Competencies, Knowledge and Skills:
- Intermediate level experience in Microsoft Word, Excel and PowerPoint
- Data analysis and trending skills
- Demonstrated understanding of claims processing and Facets functionality
- 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:
$53,400.00 - $85,600.00
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
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Create an Inclusive Environment
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Cultivate Partnerships
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Develop Self and Others
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Drive Execution
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Influence Others
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Pursue Personal Excellence
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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.
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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