Claims Provider Data Oversight Manager

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

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

• Oversee and manage enhancement of claim outcomes across existing and emerging lines of business within the Claims organization • Define and influence functional requirements for provider matching logic, Facets claim adjudication procedures, provider data loads and management, provider configuration, and end-to-end claims adjudication • Collaboratively influence claim intake, provider match logic, pre-adjudication, adjudication, post-adjudication, payment procedures, and provider data management • Facilitate translation of business requirements into technical solutions with business and technical teams • Partner with Provider Data Management and collaborate with business, architecture, and infrastructure teams to uphold service levels and stakeholder satisfaction • Lead implementation of provider data management for appropriate claim outcomes in new and existing lines of business • Identify system enhancements, provider matching logic opportunities, and data migration requirements; perform end-to-end testing when applicable • Analyze data, workflows, policies, and procedures and propose solutions for growth initiatives • Oversee provider data management process analysis; develop, document, and communicate functional requirements • Conduct data analysis, workflow evaluations, and policy assessments to refine provider data loads, improve operational efficiency, and resolve complex technology and process challenges • Organize work teams, drive consensus, establish project plans, facilitate meetings, and document recommendations and decisions • Ensure adherence to industry best practices, regulatory mandates, and contractual obligations • Foster continuous improvement of provider data management and claims processes • Drive cross-functional oversight of provider loads and accurate application of business requirements and provider matching logic • Perform other duties as requested

🎯 Requirements

• Bachelor's degree in business administration, healthcare administration, or a related field, or equivalent years of relevant work experience is required • Minimum of three (3) years of progressive experience in provider record data, claims data management, or a related field, including claims outcome analysis, is required • Facets experience is required • Project management experience is required • Proficiency in Microsoft Office suite • Proven track record of successfully implementing new managed care products • Ability to manage various complex projects and processes to completion • Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets • Outstanding written and verbal communication skills • Strong relationship management and collaboration skills • Effective listening and critical thinking skills • Strong analytical and problem-solving abilities • Project Management Professional (PMP) certification preferred • General office environment; may be required to sit or stand for extended periods of time • Occasional travel may be required based on business needs

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Equal Opportunity Employer fostering an environment of belonging that welcomes and supports individuals of all backgrounds