Operations Specialist III

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

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business