Job Summary: 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 Licensure and Certification: - None Working Conditions: - General office environment; may be required to sit or stand for extended periods of time Compensation Range: $72,200.00 - $115,500.00CareSource 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): 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. #LI-RW1

• Provide prompt, courteous and high-quality customer service to all policyholders and claimants by answering customer calls, filing claims, and resolving customer requests • Manage an inventory of litigated and non-litigated cases • Analyze and review auto insurance claims to identify areas of dispute, investigating and gathering all necessary information and documentation related to the claim, evaluating liability and damages related to the claim, and negotiating and settling claims with opposing parties or their insurance providers • Ensure compliance with specific state regulations, policy provisions, and standard operating procedures • Manage both non-litigation and litigation cases related to auto claims disputes, communicate with involved parties, attending mediations, arbitrations, and court hearings as necessary, and communicating regularly with clients, claims adjusters, attorneys, and other stakeholders • Collaborate with defense counsel, claims counsel, and litigation claims management for strategic planning, including developing and maintaining positive working relationships with approved defense firms and other vendors in the industry • Review legal documents and ensuring compliance with initial suit-handling plan of action • Serve as corporate representative for discovery review and depositions, and appearing as Corporate Representative at depositions and trials when needed • Analyze policy language and reaching appropriate coverage decisions, drafting frequent and complex coverage correspondence, and proactively managing non-litigated and litigated claim files from inception to closure • Direct and control the activities and costs of numerous outside vendors including defense counsel and coverage counsel, experts and independent adjusters • Maintain adjuster licenses and continuing education requirements

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Appeal & Grievance Coordinator will receive, investigate, and triage expedited appeal requests from members and provider representatives enrolled in Senior Products. Timely assignment of cases is critical to ensure that appeal rights are processed in accordance with regulatory standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). - Claims research and processing (more focused on understanding why claims were denied) - Authorization lookup/building authorizations and updating them - Researching outside vendor sites for authorizations and reviewing notes - Reviewing appeal letters to determine the basis of the provider's appeal - Starting the appeal process and conducting research on the appeal - Sending out appeal determination letters and completing the appeal - Extensive training on internal and external systems and the internal appeal process Qualifications - At least 1 year of experience in health insurance claims and appeals is strongly preferred - At least a high school degree; a college degree and/or extensive experience would be considered - Outbound call experience (though not a large part of this job) is a plus - A customer service background and experience, not necessarily in the healthcare field, is a nice to have - Medicaid experience desired and will make the candidate stand out

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description ManhattanLife is seeking a Claims Specialist for our office located in De Pere, WI. This role directly supports our organization’s Claims team. Claims Specialists evaluate medical claims submissions and process the claims on our systems. Our Claims Specialists also provide customer service to our policyholders over the phone. This position has the option to be remote. Duties and Responsibilities - Evaluate claims based on documentation received and provide timely follow-ups for claims being adjudicated. - Process insurance claims with adherence to company policies and contract provisions in full accordance with the law. - Make decisions and ensure the successful resolution of inquiries and complaints by preparing accurate and timely activity reports. - Communicate via written correspondence or e-mail to claimants. Qualifications - High School Graduate or equivalent (GED). - 1-3 years of claims experience preferred. - Solid knowledge of ICD-9, ICD-10 or medical coding. - Excellent phone skills and an ability to communicate in a friendly and effective manner with our customers. - Background in insurance claims is preferred in any discipline of Medicare Supplement, Life, Health, Cancer or Disability. - Ability to read and understand policy language. - Understanding of basic medical terminology. - Ability to work independently and in a team environment. - Ability to prioritize and manage workload to meet deadlines. Travel Requirements - This position does not require travel. Professional Development - Establish annual objectives for professional growth. - Keep pace with developments in the discipline. - Learn and apply technologies that support professional and personal growth. - Participate in the evaluation process. Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee is regularly required to: - Stand; walk; use hands to finger, handle or feel objects, type, and use mouse; - Reach with hands and arms and talk and/or hear; - Sit for extended periods of time; - Lifting, pulling or moving items weighing upwards of 10 pounds as it relates to office or desk supplies. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee regularly works in an office environment. This role routinely uses standard office equipment such as: - Computers; - Phones via WebEx; - Physical phone while in office; - Photocopiers when necessary. Other Duties Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to the job at any time without notice. AAP/EEO Statement ManhattanLife prohibits discrimination based on race, religion, gender, national origin, age, disability, veteran status, marital status, pregnancy, gender expression or identity, sexual orientation, or any other legally protected status. EOE Employer/Vet/Disabled. ManhattanLife values differences. We are committed to fostering an environment that attracts and retains a diverse workforce. With individuals from a variety of backgrounds, ManhattanLife will be better equipped to service our customers, increase innovation, and reduce risks. We encourage the unique perspectives of individuals and are dedicated to creating a respectful and inclusive work environment.