Job Summary:

The Senior Manager, Technical Claims Adjustments is responsible for providing leadership and direction to employees in the Claim Adjustment department to ensure the goals and standards of the department and CareSource are met.

Essential Functions:

• Provide leadership and direction to employees in the Claim Adjustment department to ensure the goals and standards of the department and CareSource are being met
• Develop metrics and leading indicators to measure technical results and create/execute action plans as needed alongside other Operational Leaders
• Ensure quantitative and qualitative measures are used to meet performance objectives
• Manage staffing and scheduling functions to meet regulatory requirements and service level agreements (SLA's)
• Drive first in class claim processing and reprocessing handling within the Claim Adjustment processes and development
• Lead direction of quality improvement efforts within claim adjustment scope through focused audits of tickets, adjustments, and processed. Point person with Quality Audit team to improve operational processes
• Lead interactions with other operational departments to identify root cause reason for incorrect claim processing and drive remediation of process improvement
• Manage communications on claim handling to ensure alignment, coordination and strategic messaging (important areas of focus, key process changes impacting the process)
• Provide clear communication of high priority items and items with significant financial impact to CareSource leadership teams, including Sr Leadership, Executive Leadership, and C-level Leadership,
• Provide leadership of processes to ensure member accumulators are consistently up to date with data from all member claims included delegated vendors
• Create consistency with respects to practices and processes for early identification root cause, adjustment methods, and execution
• Work closely with team, leadership, and cross functional teams on utilization of analytics, process automation and improving efficiencies within the Discipline. Liaison with IT on technology related initiatives, issues or changes.
• Develop and implement controls and ensure that proper communication and approvals are in place prior to completion of tickets
• Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
• Prepare and monitor various management and oversight metrics and reports as required
• Engage direct reports through consistent performance feedback and development opportunities
• Participate in strategic planning and implement action plans
• Identify and facilitate process improvements to improve productivity, accuracy, and data usability
• Lead initiatives that supports best practices for solution implementation and techniques and methods for claims payment
• Responsible for understanding industry advancements in claims processing and automation and identifying opportunities to leverage efficiencies for claim adjustments Lead operational opportunities and recommendations for automation and process improvements
• Review and analyze the effectiveness and efficiency of existing claims processes and systems, and participate in development of solutions to improve or further leverage these functions
• Ensure operational effectiveness by assisting in strategic and business planning, including business, financial, and operational goals and objectives definition as well as feasibility studies
• Recognize and proactively manage scope and expected benefits across claims strategic initiatives and process improvements and is a key contributor to the claims technical advancements
• Lead departmental efforts to locate and modify claims data anomalies that impact regulatory claims data completeness
• Manage claims adjustment automation through direction and oversight of Mass Claim Adjustment (MCA) tool, robot automation tools, and manual adjustments
• Collaborate with teams in Claims, Configuration, Claim Edits, Member Benefits, Utilization Management, Health Partnership, and around CareSource to ensure claims are processing appropriately based on the need of the entire claim payment lifecycle
• Assist in the development and implementation of departmental policies and procedures
• Oversee Claims initiatives such as working with IT and others to automate claims functions and improve front end processes, implement new business including the design, testing and delivery of supporting processes to the business
• Actively participate and partner with vendor management and procurement to secure effective and efficient vendor contracts
• Perform any other job duties as requested

Education and Experience:

• Bachelor's degree in business administration, healthcare or related field or equivalent years of relevant work experience is required
• Minimum of five (5) years of healthcare claims or operations experience is required
• Minimum of three (3) years of previous leadership experience is required

Competencies, Knowledge and Skills:

• Working knowledge of medical claims workflow and processing applications
• Knowledge of regulatory reporting and compliance requirements for Medicaid and Medicare
• Knowledge of managed care industry, claims trends and best practices
• Experience with automating processes through RPA tools and techniques
• Familiar with Agile methodology and application
• Medicaid/Medicare knowledge of managing inventory and assigning work
• Proficient in Microsoft Word and Excel
• Knowledge of medical coding (CPT, HCPCS, ICD) highly desired
• Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
• Ability to track/trend provider claim issues and develop solutions
• Excellent communication skills; both written and verbal
• Ability to work collaboratively with other management
• Time management skills; capable of multi-tasking and prioritizing work
• Effective decision making / problem solving skills
• Ability to effectively interact with senior management and executive staff
• Strong business and financial acumen preferred

Licensure and Certification:

• None

Working Conditions:

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

Compensation Range:
$90,500.00 - $158,400.00 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. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies:
- Create an Inclusive Environment - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.