Claims Provider Data Oversight Manager

CareSource; Dayton (OH); Hybrid; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking a Claims Provider Data Oversight Manager in the Dayton area to oversee enhancements in claim outcomes across existing and new lines of business. You will influence provider matching logic, facets claim adjudication, and provider data management, while leading cross-functional teams to deliver end-to-end improvements.

Ideal candidates have strong Facets knowledge, project management skills, and excellent communication for stakeholder alignment. Travel may be required.

Qualifications

• Bachelor's degree in business administration, healthcare administration, or related field; or equivalent experience.
• 3+ years of progressive experience in provider record data or claims data management; includes claims outcome analysis.
• Facets experience and project management experience required.

Responsibilities

• Define and influence provider matching logic and adjudication procedures.
• Coordinate provider data loads and provider configuration across claims processes.
• Lead cross-functional collaboration to align business and technical solutions.
• Ensure compliance with regulatory and contract obligations in new implementations.

Skills

Provider data management

Claims data analysis

Project management

Facets knowledge

Communication

Education

Bachelor's degree in business administration or healthcare administration

Tools

Facets

Microsoft Office

Job description

Job Summary

The Claims Provider Data Oversight Manager oversees and manages the enhancement of claim outcomes across existing and emerging lines of business within the Claims organization. Responsibilities include orchestrating collaborative efforts with cross-functional teams to devise and implement project strategies, mitigate risks, monitor progress, lead process optimization endeavors, and create transformative change. Expert-level comprehension of Facets and provider data with a deep understanding on the impact to the end-to-end claims process from intake to remittance, and exceptional communication and interpersonal abilities are imperative for success.

Essential Functions

Define and influence the functional requirements of provider matching logic, Facets claim adjudication procedures, provider data load and management requirements, provider configuration, and claims end-to-end adjudication processes Collaboratively influence claim intake, provider match logic, pre-adjudication, adjudication, post-adjudication, payment procedure, and provider data management Facilitate business requirements to technical solutions with business teams and technical teams for seamless alignment Partner with the Provider Data Management team to influence provider data loads; collaborate with business, architecture, and infrastructure units to uphold exceptional service levels and bolster stakeholder satisfaction Lead the seamless implementation of provider data management to ensure appropriate claim outcomes for new and existing lines of business within the Claims organization Identify future system enhancements, provider matching logic opportunities, data migration requirements and perform end-to-end testing, when applicable Perform detailed analysis of data, workflows, policies, procedures, and offer potential solutions to execute growth initiatives Oversee the analysis of provider data management processes and influence and develop functional requirements, document and communicate captured information for validation and re-usability Conduct intricate data analysis, workflow evaluations, and policy assessments to propose and execute initiatives aimed at refining provider data loads, operational efficiency and resolving complex technology and process-based challenges Organize work teams, drive consensus, and ensure end-to-end policy and process integrity to accomplish project work, including stakeholder participation; establishment of a project plan; meeting facilitation; consensus building; recommendation and decision documentation for all claim outcomes driven by provider data management oversight Stay abreast and ensure adherence of industry best practices and regulatory mandates, integrating them into claims and provider data management processes relative to claims outcomes Ensure compliance with regulatory and contract obligations in new business implementations Foster a culture of continuous improvement, contributing to the development and enhancement of provider data management and claims processes, while nurturing a high-performance team environment Drive cross-functional oversight of provider load and ensuring accurate and consistent application of business requirements and for provider data management and provider matching logic Perform any other job duties as requested.

Education and Experience

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.

Competencies, Knowledge and Skills

Proficiency in Microsoft Office suite Exceptional project management acumen, and a 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 communication skills, both written and verbal Strong relationship management and collaboration skills Effective listening and critical thinking skills Strong analytical and problem-solving abilities.

Certification

Project Management Professional (PMP) certification preferred.

Working Conditions

General office environment; may be required to sit or stand for extended periods of time Occasional travel may be required based on business needs.

Compensation Range

$83,000.00 - $132,800.00 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):

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

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.

We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

#LI-GB1 Brand=CareSource

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.