Claims Management Analyst III

Job not on LinkedIn

🕒 May 11

🇺🇸 United States – Remote

💵 $72.2k - $115.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Business Analyst

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

⚕️ Healthcare Insurance

Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Manage the EDI (Electronic Data Interchange) trading partners and network of clearinghouses to ensure accurate and timely exchange of information • Work closely with Vendor Management to improve and maintain the trading partner agreement with the trading partners, including cost reduction and adding services • Develop and maintain a partnership with the trading partner account representatives • Manage trading partner performance, establish and monitor service level agreements, regulatory requirements, and contractual metrics • Provide Subject Matter Expertise (SME) to all departments regarding eBusiness specific EDI transactions • Build, sustain, and leverage relationships to allow for continuous improvement of the EDI business process • Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements • Review and analyze the effectiveness and efficiency of existing processes and systems, and participate in development of solutions to improve or further leverage these functions • Participate in the process of estimating initiative budgets as well as developing business cases and tracking the benefits • Understand business strategy, define and lead eBusiness initiatives such as working with IT and others internal departments to automate functions • Understand the process to receive claims, claims rejections and denial processes, claims payment methodologies, adjudication processing, and Encounters to enable synergies among IT and business groups • Contribute to and/or develop user stories or provide user story guidance for sprint planning • Develop, document, and perform testing and validation as needed • Develop and maintain an in-depth knowledge of the company’s business and regulatory environments • Identify issues, risks, and mitigation opportunities • Perform any other job duties as requested

🎯 Requirements

• Bachelor’s degree or equivalent years of relevant work experience is required • Minimum of five (5) years of health care operations experience in insurance, managed care, or related industry is required • Advanced knowledge of healthcare EDI files (837, 277CA, 999, 270/271, 276/277, etc.) • Advanced computer skills • Demonstrated exceptional communication (verbal and written) and high level of professionalism • Data analysis and trending skills to include query writing • Knowledge of Claims IT processes and systems • Working knowledge of managed care and health claims processing • Ability to effectively interact with all levels of management within the organization and across multiple organizational layers • Strong interpersonal, leadership and relationship building skills • Decision making and problem solving skills • Ability to work independently and within a team environment • Time management skills; capable of multi-tasking and prioritizing work • Attention to detail • Effective decision making / problem solving skills • Critical thinking and listening skills

🏖️ Benefits

• substantial and comprehensive total rewards package • potential for bonus tied to company and individual performance