Job Summary:

The Claims Specialist III is responsible for capturing, resolving/facilitating resolution, and reporting on claim adjustment requests.

Essential Functions:

Resolve complex COB issues through member information updates and adjustment of claimsMaintain accountability for daily tasks and goals to ensure completion of requests within requested SLA and department standardsIdentify potential process improvementsWork with peers to ensure implementation of identified process improvements through the Plan, Do, Study, Act (PDSA) cycle with proper documentation updates and sharing of improvement with team and departmentProcess/adjust a wide variety of claims accurately and timely following established guidelines for accuracy, quality and productivityAct as a technical resource for training, providing job shadowing, departmental communication, and coachingEnsure all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and claims resolutions are coordinated with all appropriate departments in order to resolveAssist providers with inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal proceduresIdentify, track and trend claims payment errors in order to determine root causes and actions needed to correct problems. Work directly with Configuration, Network Operations, and Service Center through resolution of payment errors.

Ensure reporting on provider inquires and complaints is compliant with current and future regulatory and accreditation bodies such as; ODJFS, MDCH, CMS, OFIR, NCQA and URACAdhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of businessPerform any other job related instructions, as requested

Education and Experience:

High School Diploma or equivalent is requiredMinimum of one (1) year of experience in claims environment or related healthcare operations experience requiredPrevious experience in an HMO or related industry preferredPrevious Medicare/Medicaid dual eligible claims experience is preferredManaged Care Organization or related healthcare industry experience preferredFacets claims processing experience strongly preferred

Competencies, Knowledge and Skills:

Proficient in Microsoft Office Suite, to include Word, Excel and PowerPointMedical terminology; CPT and ICD coding knowledge strongly preferredKnowledge of medical billing practicesIntermediate level data entry skillsExcellent written and verbal communication skillsAbility to develop, prioritize and accomplish goalsEffective listening and critical thinking skillsStrong interpersonal skills and a high level of professionalismAbility to coach and provide feedback effectivelyEffective problem solving skills with attention to detailAbility to work independently and within a team environment

Licensure and Certification:

NoneWorking Conditions:

General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$40,400.00

• $64,700.

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:

HourlyCompetencies

• Create an Inclusive Environment
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Person