Claims Specialist - Facets Claims

5 days ago

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CareSource

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CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

Medicaid • MyCare Ohio • Health Insurance Marketplace • Medicare Advantage • Health Insurance

1001 - 5000 employees

Founded 30+ years

⚕️ Healthcare Insurance

📋 Description

• The Claims Specialist III is responsible for capturing, resolving/facilitating resolution, and reporting on claim adjustment requests. • 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. • 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 and providing job shadowing. • Ensure all assigned provider issues are resolved and communicated within appropriate timeframes. • Assist providers with inquiries including verifying proper medical coding and claims procedures. • Identify, track and trend claims payment errors to determine root causes.

🎯 Requirements

• High School Diploma or equivalent required • Minimum of one (1) year of experience in claims environment or related healthcare operations required • Previous experience in an HMO or related industry preferred • Previous Medicare/Medicaid dual eligible claims experience preferred • Managed Care Organization or related healthcare industry experience preferred • Facets claims processing experience strongly preferred • Proficient in Microsoft Office Suite, including Word, Excel and PowerPoint • Medical terminology; CPT and ICD coding knowledge strongly preferred • Knowledge of medical billing practices • Excellent written and verbal communication skills • Effective listening and critical thinking skills • Strong interpersonal skills and a high level of professionalism • Effective problem-solving skills with attention to detail • Ability to work independently and within a team environment

🏖️ Benefits

• Comprehensive total rewards package • Potential for a bonus tied to performance • Investment in employee well-being