Claims Management Analyst III

Job Summary:

The Claims Management Analyst III is responsible for leading eBusiness initiatives and coordination of activities across multiple functional areas.

Essential Functions:

• Manage the EDI (Electronic Data Interchange) trading partners and network of clearinghouses to ensure accurate and timely exchange of information
• Works closely with Vendor Management to improve and maintain the trading partner agreement with the trading partners.  This includes 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 constantly allow for continuous improvement of the EDI business process
• Responsible for eBusiness EDI requirements that support regulatory, compliance, and business needs And eBusiness EDI regulatory reporting
• 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

Education and Experience:

• 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

Competencies, Knowledge and Skills:

• 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
• Demonstrates excellent analysis, collaboration skills, facilitation and presentation skills
• 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

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