Claims Reimbursement Analyst II – Health Plan Claims, Facets Experience

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $62.7k - $100.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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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

• Perform reimbursement analysis to support accurate claims payment, contract compliance, and operational efficiency • Develop, implement, and maintain reimbursement guidelines for assigned CareSource products • Collaborate with Claims, Configuration, Provider Contracting, Provider Analytics, Operations, product owners, and other cross-functional partners • Support Benefit Interpretation activities using applicable grids, spreadsheets, and technology-based applications • Conduct legislative, regulatory, reimbursement material, and internal control reviews • Analyze reimbursement outcomes, payment data, implementation results, discrepancies, trends, variances, and anomalies across claims, providers, and products • Perform root-cause analysis, document findings and impacts, recommend corrective actions, and support issue resolution and escalation • Prepare and execute user acceptance testing, validate configuration and reimbursement logic and outputs, conduct postproduction validation, and document test results • Use reporting, query, automation, AI-enabled, and other technology-based tools to improve Claims accuracy, quality, execution, analysis, and issue identification • Develop recurring, ad hoc, and required reports and business decision documents for internal stakeholders and external governing bodies • Identify and manage risks, implement mitigation strategies, and communicate or escalate concerns • Lead and participate in initiatives and team meetings; establish and execute detailed tasks • Support budgets, timelines, milestones, and task schedules, collaborating with senior leadership on initiative funding, resourcing, and management • Execute Claims-related policies and procedures and provide stakeholders with status updates, clarification, and verification • Provide guidance, support, and training to Claims and Operations • Leverage automation and AI-enabled tools to identify reimbursement trends, anomalies, and improvement opportunities • Perform other job-related duties as requested

🎯 Requirements

• Bachelor's degree in Business, Healthcare Administration, Finance, Analytics, or a related field required; equivalent years of relevant work experience may be accepted in lieu of required education • Three (3) years of product management, reimbursement policy creation, or claims experience required • Two (2) years of experience in healthcare reimbursement, claims analysis, or payment operations required • Familiarity with the healthcare/managed care field and knowledge of government program products required • Previous experience working with state and federal regulators/government in a managed care setting preferred • Working knowledge of healthcare reimbursement, claims processing, and provider contracting concepts • Strong analytical, critical thinking, and problem-solving skills • Ability to evaluate payment data, identify trends and anomalies, determine root causes, and recommend solutions with a high degree of accuracy and attention to detail • Ability to translate analytical findings into clear documentation and actionable recommendations • Proficiency with claims systems, reporting tools, data analysis applications, and Microsoft Office Suite, including advanced Excel skills • Understanding of regression, unit, and user acceptance testing methodologies • Familiarity with payment methodologies and industry pricers, such as DRG, APC, SNF, and RBRVS, preferred • Strong written and verbal communication skills • Ability to build relationships and collaborate effectively across cross-functional teams • Ability to work independently and collaboratively in a fast-paced, matrixed environment while managing multiple priorities and meeting project deadlines • Customer service mindset with a strong member and provider focus • Decision-making and problem-solving skills with a demonstrated ability to execute • Licensure and Certification: None

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support • Travel is not typically required

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