REMOTE - Manager, Claims Adjustments & MCA - R10887

Job SummaryThe Manager, Claims Adjustments & Mass Claim Adjustment (MCA) is responsible for providing leadership and direction to employees in the Claim Adjustment department to ensure the goals and standards of the department and CareSource are met.Essential FunctionsManage staffing and scheduling functions to meet regulatory requirements and service level agreements (SLA’s)Oversee orientation and training of new team members and direct day-to-day staff activities to ensure service and performance objectives are achievedEngage direct reports through consistent performance feedback and development opportunitiesManage and maintain reporting dashboards for inventory and root cause identificationHave a deep understanding of the claim adjudication process to lead and develop team to increases in accurate automation of claimsManage claims adjustment automation through direction and oversight of MCA tool, robot automation tools, and manual adjustmentsResearch and propose automation advancements; engage appropriate cross functional areas for solution development and implementationEnsure root cause identification occurs on adjustment ticket to identify and remediate claim system issuesPrioritize tickets, projects, and escalations according to market and strategic needsProvide oversight of claim adjustment ticketing solution (OnBase, Service Now, SharePoint, Facets, TFS, email)Ensure claim adjustment team members identify, escalate and/or resolve complex or non-routine questions, issues, and problems within SLA timelines and provide direction as needed and/or escalate to senior management as appropriateEnsure that proper communication and approvals are in place prior to completion of ticketsManage communications on claim handling to ensure alignment, coordination, and strategic messaging (key areas of focus, key process changes impacting the process)Create consistency with respects to practices and processes for early identification of root cause, adjustment methods, and executionCollaborate closely with team, leadership, and cross functional teams on utilization of analytics, process automation and improving efficienciesIdentify and facilitate process improvements to improve productivity, accuracy, and data usabilityResponsible for understanding industry advancements in claims processing and automation and identifying opportunities to leverage efficiencies for claim adjustmentsCollaborate with teams in Claims, Configuration, Claim Edits, Member Benefits, Utilization Management, Health Partnership, and around CareSource to ensure claims are processing appropriately based on the need of the entire claim payment lifecycleAssist in the development and implementation of departmental policies and proceduresOversee Claims initiatives such as working with IT and others to automate claims functions and improve front end processes, implement new business including the design, testing and delivery of supporting processes to the businessActively participate and partner with vendor management and procurement to secure effective and efficient vendor contractsPerform any other job duties as requestedEducation And ExperienceBachelor’s degree in business administration, healthcare a related field or equivalent years of relevant work experience is requiredFour (4) years of healthcare claims or operations experience is requiredTwo (2) years of previous leadership experience is requiredFACETS Claims experience requiredCompetencies, Knowledge And SkillsWorking knowledge of medical claims workflow and processing applicationsKnowledge of regulatory reporting and compliance requirements for Medicaid and MedicareKnowledge of managed care industry, claims trends and best practicesKnowledgeable in automating processes through RPA tools and techniquesFamiliar with Agile methodology and applicationMedicaid/Medicare knowledge of managing inventory and assigning workProficient in Microsoft Word and ExcelKnowledge of medical coding (CPT, HCPCS, ICD) highly desiredAdvanced working knowledge of managed care and health claims processing and reimbursement methodologiesAbility to track/trend provider claim issues and develop solutionsExcellent communication skills; both written and verbalAbility to work collaboratively with other managementTime management skills; capable of multi-tasking and prioritizing workEffective decision making / critical thinking skillsAbility to effectively interact with senior management and executive staffStrong business and financial acumen preferredLicensure And CertificationNoneWorking ConditionsGeneral office environment; may be required to sit or stand for extended periods of timeCompensation Range$81,400.00 - $130,200.00 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 TypeSalaryCompetencies Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis 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.