Claims Specialist III

Claims Specialist III

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 inquiries 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 :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

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 (hourly / salary) : Hourly

Organization Level Competencies :

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. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.