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

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:

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

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 environment of belonging that welcomes and supports individuals of all backgrounds.