Claims Provider Data Oversight Manager

Job Summary:

The Claims Provider Data Oversight Manager oversees and manages the enhancement of claim outcomes across existing and emerging lines of business within the Claims organization. Responsibilities include orchestrating collaborative efforts with cross-functional teams to devise and implement project strategies, mitigate risks, monitor progress, lead process optimization endeavors, and create transformative change. Expert-level comprehension of Facets and provider data with a deep understanding on the impact to the end-to-end claims process from intake to remittance, and exceptional communication and interpersonal abilities are imperative for success.

Essential Functions:

• Define and influence the functional requirements of provider matching logic, Facets claim adjudication procedures, provider data load and management requirements, provider configuration, and claims end-to-end adjudication processes
• Collaboratively influence claim intake, provider match logic, pre-adjudication, adjudication, post-adjudication, payment procedure, and provider data management
• Facilitate business requirements to technical solutions with business teams and technical teams for seamless alignment
• Partner with the Provider Data Management team to influence provider data loads; collaborate with business, architecture, and infrastructure units to uphold exceptional service levels and bolster stakeholder satisfaction
• Lead the seamless implementation of provider data management to ensure appropriate claim outcomes for new and existing lines of business within the Claims organization
• Identify future system enhancements, provider matching logic opportunities, data migration requirements and perform end-to-end testing, when applicable
• Perform detailed analysis of data, workflows, policies, procedures, and offer potential solutions to execute growth initiatives
• Oversee the analysis of provider data management processes and influence and develop functional requirements, document and communicate captured information for validation and re-usability
• Conduct intricate data analysis, workflow evaluations, and policy assessments to propose and execute initiatives aimed at refining provider data loads, operational efficiency and resolving complex technology and process-based challenges
• Organize work teams, drive consensus, and ensure end-to-end policy and process integrity to accomplish project work, including stakeholder participation; establishment of a project plan; meeting facilitation; consensus building; recommendation and decision documentation for all claim outcomes driven by provider data management oversight
• Stay abreast and ensure adherence of industry best practices and regulatory mandates, integrating them into claims and provider data management processes relative to claims outcomes
• Ensure compliance with regulatory and contract obligations in new business implementations
• Foster a culture of continuous improvement, contributing to the development and enhancement of provider data management and claims processes, while nurturing a high-performance team environment
• Drive cross-functional oversight of provider load and ensuring accurate and consistent application of business requirements and for provider data management and provider matching logic
• Perform any other job duties as requested

Education and Experience:

• Bachelor's degree in business administration, healthcare administration, or a related field or equivalent years of relevant work experience is required
• Minimum of three (3) years of progressive experience in provider record data, claims data management or a related field, including claims outcome analysis, is required
• Facets experience is required
• Project management experience is required

Competencies, Knowledge and Skills:

• Proficiency in Microsoft Office suite
• Exceptional project management acumen, and a proven track record of successfully implementing new managed care products
• Ability to manage various complex projects and processes to completion
• Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets
• Outstanding communication skills, both written and verbal
• Strong relationship management and collaboration skills
• Effective listening and critical thinking skills
• Strong analytical and problem-solving abilities

Certification:

• Project Management Professional (PMP) certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Occasional travel may be required based on business needs

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

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.

Originally posted on Himalayas