Claims Management Analyst III

📋 Description

• • As a Claims Management Analyst III at CareSource Management Group Company, you will be at the forefront of driving critical eBusiness initiatives, acting as a central point of coordination across diverse functional areas to ensure the seamless and efficient exchange of vital healthcare information.
• • Your primary responsibility will involve the meticulous management of Electronic Data Interchange (EDI) trading partners and a network of clearinghouses. This entails ensuring the accuracy, timeliness, and integrity of all data exchanged, which is fundamental to our operational success and the delivery of quality healthcare services.
• • You will collaborate closely with the Vendor Management team to not only maintain but also enhance our trading partner agreements. This strategic partnership will focus on identifying opportunities for cost reduction and the expansion of services, thereby maximizing the value derived from these crucial relationships.
• • A key aspect of your role will be to cultivate and nurture strong, collaborative partnerships with account representatives from our trading partners. This proactive engagement is essential for fostering mutual understanding and driving continuous improvement.
• • You will be tasked with rigorously managing trading partner performance. This includes establishing, monitoring, and enforcing Service Level Agreements (SLAs), ensuring adherence to all regulatory requirements, and tracking key contractual metrics to guarantee optimal performance and compliance.
• • As a Subject Matter Expert (SME) in eBusiness and EDI transactions, you will provide invaluable guidance and support to all departments. Your deep understanding will empower teams to navigate complex EDI processes and leverage these capabilities effectively.
• • Building, sustaining, and leveraging relationships will be paramount to your success. You will actively work to foster an environment of continuous improvement within our EDI business processes, identifying bottlenecks and implementing solutions.
• • You will be accountable for defining and implementing eBusiness EDI requirements that align with and support regulatory mandates, compliance standards, and overarching business needs. This includes ensuring the accuracy and timeliness of eBusiness EDI regulatory reporting.
• • A significant part of your role will involve providing critical reporting and insightful analysis of functional performance. Based on your findings, you will make data-driven recommendations for enhancements, cost-saving initiatives, and strategic process improvements.
• • You will be expected to meticulously review and analyze the effectiveness and efficiency of existing processes and systems. Your insights will contribute to the development of innovative solutions designed to improve current functions or leverage them more effectively.
• • You will actively participate in the financial planning process by contributing to the estimation of initiative budgets. Furthermore, you will be instrumental in developing compelling business cases and diligently tracking the realized benefits of these initiatives.
• • A deep understanding of our business strategy is essential. You will translate this understanding into the definition and leadership of eBusiness initiatives, working collaboratively with the IT department and other internal stakeholders to automate critical functions and streamline operations.
• • You will develop a comprehensive understanding of the entire claims lifecycle, including processes for receiving claims, handling rejections and denials, understanding claims payment methodologies, adjudication processing, and encounter data. This holistic view will enable you to identify synergies between IT and business groups.
• • You will contribute to the Agile development process by developing and/or providing guidance on user stories for sprint planning, ensuring that technical solutions align with business requirements.
• • Developing, documenting, and executing thorough testing and validation procedures will be a key responsibility to ensure the reliability and accuracy of our systems and processes.
• • You will be expected to develop and maintain an in-depth, up-to-date knowledge of the company’s business operations and the complex regulatory environments in which we operate.
• • Proactively identifying issues, potential risks, and opportunities for mitigation will be crucial for safeguarding our operations and ensuring project success.
• • You will perform any other job duties as requested, demonstrating flexibility and a commitment to supporting the team's objectives.