Claims Management Analyst III

Claims Management Analyst III at CareSource

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
• Works closely with Vendor Management to improve and maintain the trading partner agreement with the trading partners. This includes 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 constantly allow for continuous improvement of the EDI business process
• Responsible for eBusiness EDI requirements that support regulatory, compliance, and business needs And eBusiness EDI regulatory reporting
• Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
• Review and analyze the effectiveness and efficiency of existing processes and systems, and participate in development of solutions to improve or further leverage these functions
• Participate in the process of estimating initiative budgets as well as developing business cases and tracking the benefits
• Understand business strategy, define and lead eBusiness initiatives such as working with IT and others 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

Working Conditions

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

Key skills/competency

• EDI Management
• Claims Processing
• Healthcare Operations
• Regulatory Compliance
• Data Analysis
• Vendor Relationship Management
• Process Improvement
• eBusiness Initiatives
• Subject Matter Expertise
• Cross-functional Collaboration