Operations Regulatory Specialist II (Hybrid location)

Job Summary:

The Operations Regulatory Specialist II provides analytical support and leadership for key internal Operations projects and partners with the Operations departments to ensure all regulatory and compliance deliverables are met. This position will work Tues/Thurs in the Dayton, Ohio office and remote the other days.

Essential Functions:

• Represent operations on cross-functional project work teams
• Submit, monitor and prioritize IT tickets for the operations departments
• Review special projects and identify issue trends and potential resolutions
• Assist with reporting and processes that are regulatory related and tied to state issues deadlines
• Assist with the development, drafting and review of P&P’s and job aides for Operations
• Assist in educating/training Business Partners on operations functions.
• Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
• Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
• Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
• Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include:
  • Documentation gathering – i.e. review of Standard Operating Procedure and/or Policy and Procedure to the audit/inquiry requirements
  • Audit Universe monitoring and/or creation – collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submission
  • Prepare Operations Business Owners for live questions and answers with the state regulators or auditors
  • Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
  • Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
  • Track all Compliance required training on a yearly and new hire basis for Operations
  • Assist with all readiness activities in relation to implementation of a new line of business for Operations
• 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 operations environment is required
• Regulatory and/or compliance experience is 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

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business