Claims Specialist III

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 claims
• Maintain accountability for daily tasks and goals to ensure completion of requests within requested SLA and department standards
• Identify potential process improvements
• Work 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 department
• Process/adjust a wide variety of claims accurately and timely following established guidelines for accuracy, quality and productivity
• Act as a technical resource for training, providing job shadowing, departmental communication, and coaching
• Ensure 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 resolve
• Assist providers with inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal procedures
• Identify, 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 URAC
• Adhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of business
• Perform any other job related instructions, as requested

Education and Experience:

• High School Diploma or equivalent is required
• Minimum of one (1) year of experience in claims environment or related healthcare operations experience required
• Previous experience in an HMO or related industry preferred
• Previous Medicare/Medicaid dual eligible claims experience is preferred
• Managed Care Organization or related healthcare industry experience preferred

Competencies, Knowledge and Skills:

• Proficient in Microsoft Office Suite, to include Word, Excel and PowerPoint
• Medical terminology; CPT and ICD coding knowledge strongly preferred
• Knowledge of medical billing practices
• Intermediate level data entry skills
• Excellent written and verbal communication skills
• Ability to develop, prioritize and accomplish goals
• Effective listening and critical thinking skills
• Strong interpersonal skills and a high level of professionalism
• Ability to coach and provide feedback effectively
• Effective problem solving skills with attention to detail
• Ability to work independently and within a team environment

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