Operations Specialist II (Remote/Hiring ASAP)

Job Summary:

The Operations Specialist II provides analytical support and leadership for projects impacting Claims and key internal Claims projects, with a focus on readjudicating claims to pay appropriately following correction of systemic issues. Both healthcare claims and Facets experience are required. This position is full-time, remote.

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
Deep analytical skills with ability to identify trends
Intermediate to advanced claims knowledge
Intermediate to Advanced Excel Skills (e.g. pivot tables, VLOOKUPs, etc.)
Basic to Intermediate SQL skills

Licensure and Certification:

None

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Organization Level Competencies

Leveraging Feedback
Customer Orientation
Valuing Differences
Managing Work
Earning Trust
Quality Orientation
Adaptability
Influencing
Collaborating

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, including disability and veteran status. We are committed to a diverse and inclusive work environment.

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