Medical Claims Review Manager jobs in Dayton, OH

Job Summary:

The Claims Lifecycle Process Manager is responsible for leading and managing the efforts to improve the claim outcomes for existing and new lines of business within the Claims organization. This will involve working closely with cross-functional teams to develop and execute project plans, manage risks, track progress, lead process improvement initiatives, and drive change. A strong understanding of the end-to-end claims process from ingestion to remittance, experience with project management, and excellent communication and interpersonal skills is required.

Essential Functions:

• Understand, define, and influence functional, usability, reliability, performance, and support requirements of claims end-to-end adjudication processes including claim intake, pre-adjudication, adjudication, post-adjudication, and payment process
• Develop and execute implementation plans, including timelines, budgets, and resource allocation
• Manage risk and ensure implementation activities are completed on time and within budget
• Provide the link between the technical and business views of the system by ensuring the technical solutions being developed meet the needs of the business
• Partner with business, architecture, and infrastructure and oversee all service levels to ensure business area satisfaction
• Lead and manage the implementation of new lines of business within the Claims organization
• Proactively work with stakeholders to identify future system opportunities and enhancements
• Track progress and provide regular updates to stakeholders
• Organize work teams, drive consensus, and ensure end-to-end policy/process integrity to accomplish project work, including: identification and confirmation of participants; establishment of a project plan; consistent work team engagement and productivity; meeting facilitation; consensus building; recommendation documentation, and implementation oversight
• Perform detailed analysis of data, workflows, policies, procedures, organization of staff, skills and offer potential solutions to execute initiatives
• Partner with operational leadership teams to resolve complex technology, data, and process-based issues, gaps, and risks
• Oversee the analysis of business processes and development of functional requirements and appropriately document and communicate captured information for validation and re-usability
• Identify and resolve issues that arise during implementation
• Stay up to date on industry best practices and regulations
• Contribute to the development and improvement of claims processes
• Perform other job duties as assigned

Education and Experience:

• Bachelor's degree in business administration,healthcare administration,or a related field, or equivalent years of relevant experience is required
• Minimum of five (5) years of experience in claims management or a related field is required
• Minimum of three (3) years of experience with project management is required.
• Facets experience highly preferred

Competencies, Knowledge and Skills:

• Proficient with Microsoft Office to include Word, Excel and PowerPoint
• Proven track record of successfully implementing new managed care products
• Strong understanding of the claims processes including but not limited to electronic ingestion, automated adjudication, remittance, reimbursement methodology, and compliance
• Demonstrated in-depth knowledge of Facets, Pre-adjudication, Post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, and Project Management toolset
• Excellent communication and interpersonal skills
• Effective listening and critical thinking skills
• Ability to work effectively in a fast-paced environment
• Strong analytical and problem-solving skills
• Ability to manage multiple priorities and deadlines
• Ability to create and maintain effective working relationships

Licensure and Certification:

• Project Management Professional Certificate (PMP) preferred

Working Conditions:

• General office environment, may be required to sit or stand for extended periods of time
• Ability to travel as required by the needs of the business

Compensation Range:
$79,800.00 - $127,600.00 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. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

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, including disability and veteran status. We are committed to a diverse and inclusive work environment.