Operations Specialist II (Facets Dual Processing)

Job Summary:

The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects.

Essential Functions:

• Represent claims on cross-functional project work teams
• Submit, monitor and prioritize IT tickets for the Claims department
• Review special projects and identify issue trends and potential resolutions
• Assist with Onbase reporting and processes
• Develop and draft P&P’s and job aides for Claims
• Assist in training claims staff on claims processing policy and procedures
• Assist in educating/training  Business Partners on claims functions
• Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data.
• Perform analysis of all claims data in order to provide decision support to Claims management team
• Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
• If assigned to Research and Resolution team, responsibilities include:
  • Represent Claims Department at requested provider calls and visits
  • Provide feedback and/or face-to-face interaction with providers for claims research and resolution
  • Responsible for research and resolution of claims issues for all assigned provider inquiries and submissions
  • Responsible for managing provider issues adhering to Workflow processes and tools (Facets and Onbase)
  • Provide input for claims business requirements, testing processes and implementation tasks and plans
• Perform any other job related instructions, as requested

Education and Experience:

• Bachelor’s degree or equivalent years of relevant work experience required
• Minimum of two (2) years of healthcare claims environment is required
• Facets high dollar claims manual verification highly preferred
• Facets dual product claims processing/adjudication highly preferred

Competencies, Knowledge and Skills:

• Advanced level experience in Microsoft Word, Excel and PowerPoint
• Data analysis and trending skills
• Demonstrated understanding of claims operations specifically related to managed care
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field
• Critical listening and thinking skills
• Negotiation skills/experience
• Strong interpersonal skills
• Proper grammar usage
• Technical writing skills
• Time management skills
• Strong communication skills, both written and verbal
• Customer service orientation
• Decision making/problem solving 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

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business