REMOTE - Operations Specialist III - R12711

Job SummaryThe Operations Specialist III provides analytical support and leadership for key Claims-related projects.Essential FunctionsRegulatory reporting such as CMS and Medicaid Prompt PayServe as high dollar claims reviewerIdentify payment integrity issues with claims reimbursement methodologiesPrepare and deliver responses to legal correspondence and state complaintsProvide Claims Subject Matter Expertise (SME) for cross-functional meetings including operational and new business implementationAct as primary Claims Representative and SME for corporate projectsAct as primary Claims Representative on external auditsAssist in development of policies and procedures for claims processing, COB, appeals and adjustment functionsLead Claims initiatives such as working with IT and others to automate claim functions; improve front end paper claim process; and report development with SISContribute to and/or develop user stories or provide user story guidance for sprint planningImplement new business including the design, testing and delivery of supporting processes to the businessPerform any other job related instructions, as requestedEducation And ExperienceBachelor’s degree or equivalent years of relevant work experience requiredMinimum of five (5) years of healthcare claims environment, equivalent managed care, healthcare operations or professional industry experience is requiredCompetencies, Knowledge And SkillsAdvanced proficiency level experience in Microsoft Word, Excel and PowerPointData analysis and trending skillsWork with accumulatorsDemonstrated understanding of claims operations specifically related to managed careAdvanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS codingEffective communication skillsStrategic management skillsAbility to work independently and within a team environmentAttention to detailCritical listening and thinking skillsNegotiation skills/experienceTechnical writing skillsTime management skillsDecision making/problem solving skillsLicensure And CertificationNoneWorking ConditionsGeneral office environment; may be required to sit or stand for extended periods of timeCompensation Range$72,200.00 - $115,500.00 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. 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 TypeSalaryCompetencies Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis 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 environment of belonging that welcomes and supports individuals of all backgrounds.