REMOTE - Claims Mgmnt Analyst III (HealthPlan EDI experience required) - R8692

CareSource; United States; Remote; USD 70,000 - 114,000; Full time

Job summary

An established industry player is seeking a Claims Management Analyst III to lead eBusiness initiatives and improve operations. This role involves managing EDI trading partners, ensuring compliance, and enhancing performance through data analysis. The ideal candidate will have advanced knowledge of healthcare EDI files and exceptional communication skills. Join a supportive environment that values your contributions and offers a comprehensive rewards package, including potential bonuses. This is a fantastic opportunity for those passionate about healthcare operations and looking to make a significant impact.

Benefits

Comprehensive total rewards package

Potential bonuses tied to performance

Qualifications

• Bachelor's degree or equivalent experience required.
• Minimum of 5 years in healthcare operations or related field.

Responsibilities

• Manage EDI trading partners for accurate information exchange.
• Provide SME on EDI transactions across departments.
• Analyze performance and recommend process improvements.

Skills

Healthcare EDI files knowledge

Data analysis and trending

Communication skills

Leadership skills

Problem solving skills

Time management

Education

Bachelor's degree

5+ years of healthcare operations experience

Tools

Advanced computer skills

Job description

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.
• 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.
• Responsible for eBusiness EDI requirements that support regulatory, compliance, and business needs, including eBusiness EDI regulatory reporting.
• Provide critical reporting and analysis of functional performance, making recommendations for enhancements, cost savings initiatives, and process improvements.
• Review and analyze the effectiveness and efficiency of existing processes and systems, participating in development of solutions to improve or further leverage these functions.
• Participate in the process of estimating initiative budgets, developing business cases, and tracking benefits.
• Understand business strategy and define and lead eBusiness initiatives, working with IT and other 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:
$70,800.00 - $113,200.00. 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:
Salary.

Competencies:
- Create an Inclusive Environment
- 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 inclusive environment that welcomes and supports individuals of all backgrounds.