CareSource

Title: Operations Specialist II Location: USA time type: Full time job requisition id: R13119 Job Description: Job Summary: The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects. Essential Functions: - Represent claims on cross-functional project work teams - Submit, monitor and prioritize IT tickets for the Claims department - Review special projects and identify issue trends and potential resolutions - Assist with Onbase reporting and processes - Develop and draft P&P’s and job aides for Claims - Assist in training claims staff on claims processing policy and procedures - Assist in educating/training Business Partners on claims functions - Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data. - Perform analysis of all claims data in order to provide decision support to Claims management team - Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues - If assigned to Research and Resolution team, responsibilities include: - Represent Claims Department at requested provider calls and visits - Provide feedback and/or face-to-face interaction with providers for claims research and resolution - Responsible for research and resolution of claims issues for all assigned provider inquiries and submissions - Responsible for managing provider issues adhering to Workflow processes and tools (Facets and Onbase) - Provide input for claims business requirements, testing processes and implementation tasks and plans - 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 claims environment is required 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: $62,700.00 - $100,400.00 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. 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 - 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. #LI-RW1

• Drive and encourage innovative investigative processes and workflows • Direct the day-to-day activities of investigative staff • Serve as investigative planning consultant to teams • Monitor and prioritize investigation allocation • Identify knowledge gaps and provide training opportunities • Mentor direct reports including coaching and performance feedback • Identify workflow and process inefficiencies • Collaborate cross functionally with investigative teams • Maintain knowledge of Health Care Fraud trends and schemes

• The Financial Analyst I assists in the analysis for utilization and financial trends, costs, revenues, financial commitments and obligations incurred to predict future revenues and expenses. • Highly involved in the development, production, and validation of reports from detailed claims, eligibility, pharmacy and clinical data. • Compile and analyze financial and clinical information, including but not limited to preparing the evaluation of medical contracts, product lines, generating and managing medical and administrative cost saving initiatives, etc. • Ensure integrity of information obtained for analysis; keep an up-to-date knowledge of the computer information system. • Assist in the development of revenue & medical expense forecast and budget and monitor monthly variances to identify trends. • Identify and research trends and patterns using standard departmental reports and databases, as well as leveraging other processes and data sources for data mining. • Suggest appropriate improvements to internal analysis processes ensuring that practices are in line with the overall goals of the organization. • Support the financial control environment by reconciling internal data sets vs information provided by the State (such as, reconcile enrollment files to reimbursement records, etc.). • Utilize key analysis experience and knowledge to analyze and report medical, contract and administrative activity. • Make appropriate changes to ensure compliance with MAR, regulatory and other organization requirements. • Perform any other job related instructions as requested.

• Provides Behavioral Health coverage determination for utilization management • Assumes responsibility for the overall safety of patients with a BH diagnosis • Serves as the clinical lead in developing and implementing evidenced based clinical policies and practices • Participates in regulatory/accreditation reviews

• Guide and coach the Scrum Team and organization on how to use Agile/Scrum practices and values • Provide support to the team using a servant leadership style and lead by example • Responsible to hold team accountable to the tenants of agile and working agreements including the use of appropriate tools, standards and best practices • Promote and demonstrate core agile principles of collaboration, prioritization, team accountability and visibility • Empower the team to self-organize around achievement of their commitments • Identify and remove any impediments and distractions that interfere with the team’s ability to deliver against their commitments • Recommend improvements and assist in changes to best practice where appropriate • Assist the team in tracking and communicating team progress and metrics • Facilitate and enable an environment of collaboration and creativity • Assess the Agile/Scrum maturity of the team and organization • Coach the team to higher levels of maturity, at a pace that is sustainable and comfortable for the team and organization • Build a trusting and safe environment where problems can be raised without fear of blame, retribution, or being judged • Facilitate getting the work done without coercion, assigning, or dictating the work • Facilitate discussion, decision making, and conflict resolution • Assist with internal and external communication, improving transparency, and radiating information for better visibility • Support and educate the Product Owner, especially with respect to refining and managing the product backlog

• Provide analytical support and leadership for project impacting Claims and key internal Claims projects • Represent claims on cross-functional project work teams • Submit, monitor and prioritize IT tickets for the Claims department • Review special projects and identify issue trends and potential resolutions • Assist with Onbase reporting and processes • Develop and draft P&P’s and job aides for Claims • Assist in training claims staff on claims processing policy and procedures • Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data • Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues

• Provide leadership and direction to ensure team goals and strategies are successfully achieved • Responsible for pricing, forecasting, reserving or other actuarial processes • Develop and communicate actionable and strategic recommendations to leadership • Manage the development and maintenance of actuarial models • Own the actuarial processes • Perform any other job related instructions as requested

Role Description The Onboarding Specialist is the primary contact for members as they transition to a CCA health plan. The Specialist contacts new members via telephonic outreach and identifies both the member's existing healthcare services that will continue and new service requests. The Specialist works to ensure that member needs are addressed through liaising with internal CCA providers and external healthcare providers. The Specialist also educates the member on health plan offerings and addresses members' questions or concerns. - Serves as the primary member contact and advocate until their care team is established, both through direct member outreach and inbound call support. - Leverages internal and external resources (such as claims, referrals, and pharmacy data) to identify accurate, successful contact information for unreachable or hard-to-reach members. - Orients new members to the value of CCA as their health plan, providing education, answering members’ questions, anticipating, and meeting member needs and concerns. - Documents members’ current healthcare services and new service requests. - Ensures members continue to receive current healthcare services as they transition to CCA through healthcare provider outreach and education. - Schedules new members’ initial nurse intake visits. - Utilizes communication skills such as motivational interviewing to gain agreement from members to participate in the onboarding process, persistently forging trusting relationships and engaging individuals not readily interested in connecting with CCA. - Utilizes established workflows and collaborates with internal and external stakeholders and healthcare providers. - Provides clinical care to members via telehealth technologies (video, chat, etc.) for clinically appropriate clinical care and care management services. - Performs any other job-related duties as requested. Qualifications - Bachelor's Degree or relevant experience in call center and/or Medicare/Medicaid plan required. - Equivalent years of relevant work experience may be accepted in lieu of required education. - Five (5) years of relevant experience required. - One (1) year working in outreach or in the community with individuals who have behavioral, medical, social, or interpersonal complexities impacting their lives required. - Experience working in a multi-cultural setting required. - Experience using motivational interviewing techniques in a professional setting required. - Experience identifying unmet healthcare needs and escalating to the appropriate individual preferred. - Experience with electronic medical record and care management systems strongly preferred. Requirements - Demonstrated understanding of the community served. - Familiarity with data entry and querying databases to identify key information about members. - Excellent communication skills, including the ability to convey information clearly telephonically and in a culturally sensitive manner. - Strong interpersonal and customer relation skills, including active listening skills, dependability, and responsiveness. - Compassionate, understanding, and patient. - Motivates, empowers, inspires, and collaborates with members while effectively establishing boundaries by clarifying roles, expectations, and deliverables. - Ability to develop and maintain positive working relationships with peers, supervisors, and other organizations. - Knowledge of some medical terminology preferred. - Ability to multitask and ensure all work is completed thoroughly and completely in a fast-paced environment with competing demands. - Basic computer skills. - Professional, comprehensive, clear documentation. - Familiarity with Microsoft Office programs: Outlook, Calendar, Word. - Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services. Benefits - Compensation Range: $47,400.00 - $76,000.00. - 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. Working Conditions - General office environment; may be required to sit or stand for extended periods of time. - Travel is not typically required. Licensure and Certification - None. Company Description 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.

• Collaborate with the Service Excellence team to improve the experience for customers (Member & Provider) • Drive innovation and efficiencies within the call center • Explore and apply AI capabilities to improve how we collect, analyze, and act on customer insights • Evolve enterprise Voice of the Customer (VoC) and Customer Experience (CX) programs across all lines of business • Explore and experiment with new methods, tools and automation for gathering sentiment • Define and prioritize the AI roadmap for call center initiatives • Define success metrics, measure outcomes, and track AI initiative impact over time • Stay updated on AI trends and best practices for customer research • Manage call center analysis efforts that drive measurement, prioritization, and implementation of identified opportunities • Prepare stakeholder materials, demos, and use case summaries • Act as liaison with call monitoring vendor • Lead and mentor Voice of the Customer Insights Analysts

• Responsible for making medical records audit payment decisions on a wide variety of claim complexities within department standards • Responsible for researching, analyzing, and making audit payment decisions on moderately complicated claims based on medical coding guidelines and policies • Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business • Responsible for meeting productivity standards while maintaining quality as outlined in SOP • Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager • Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions • Responds to simple escalation and provider inquiries • Prepares claim audit summaries for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed • Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims • Responsible for identifying systemic and process issues problems/concerns and reporting them to management • Responsible for backing up administrative duties in medical record acquisition processes • Responsible for identification of training and quality areas to be shared with management • Perform any other job related duties as requested