CareSource
Operations Regulatory Specialist II (Hybrid)
CareSource, Dayton, Ohio, United States, 45402
Job Summary:The Operations Regulatory Specialist II provides analytical support and leadership for key internal Operations projects and partners with the Operations departments to ensure all regulatory and compliance deliverables are met.This position is hybrid, Tuesday/Thursdays are core days in the office.
Essential Functions:Represent operations on cross-functional project work teamsSubmit, monitor and prioritize IT tickets for the operations departmentsReview special projects and identify issue trends and potential resolutionsAssist with reporting and processes that are regulatory related and tied to state issues deadlinesAssist with the development, drafting and review of P&P's and job aides for OperationsAssist in educating/training Business Partners on operations functions.Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by CompliancePerform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requestsIdentify and quantify data issues within Claims and assist in the development of plans to resolve data issuesPartner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include:
Documentation gathering - i.e. review of Standard Operating Procedure and/or Policy and Procedure to the audit/inquiry requirementsAudit Universe monitoring and/or creation - collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submissionPrepare Operations Business Owners for live questions and answers with the state regulators or auditorsTrack and assist with remediation efforts for Corrective Action Plans related to all audit findingsEnsure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for OperationsTrack all Compliance required training on a yearly and new hire basis for OperationsAssist with all readiness activities in relation to implementation of a new line of business for Operations
Perform any other job-related instructions, as requested
Education and Experience:Bachelor's degree or equivalent years of relevant work experience requiredMinimum of two (2) years of healthcare operations environment is requiredRegulatory and/or compliance experience is preferred
Competencies, Knowledge and Skills:Advanced level experience in Microsoft Word, Excel and PowerPointData analysis and trending skillsDemonstrated understanding of claims operations specifically related to managed careAdvanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS codingAbility to work independently and within a team environmentAttention to detailFamiliarity of the healthcare fieldCritical listening and thinking skillsNegotiation skills/experienceStrong interpersonal skillsProper grammar usageTechnical writing skillsTime management skillsStrong communication skills, both written and verbalCustomer service orientationDecision making/problem solving skills
Licensure and Certification:None
Working Conditions:General office environment; may be required to sit or stand for extended periods of time
Compensation Range:$60,300.00 - $96,500.00 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:SalaryCompetencies:- Create an Inclusive Environment- 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 inclusive environment that welcomes and supports individuals of all backgrounds.
Essential Functions:Represent operations on cross-functional project work teamsSubmit, monitor and prioritize IT tickets for the operations departmentsReview special projects and identify issue trends and potential resolutionsAssist with reporting and processes that are regulatory related and tied to state issues deadlinesAssist with the development, drafting and review of P&P's and job aides for OperationsAssist in educating/training Business Partners on operations functions.Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by CompliancePerform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requestsIdentify and quantify data issues within Claims and assist in the development of plans to resolve data issuesPartner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include:
Documentation gathering - i.e. review of Standard Operating Procedure and/or Policy and Procedure to the audit/inquiry requirementsAudit Universe monitoring and/or creation - collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submissionPrepare Operations Business Owners for live questions and answers with the state regulators or auditorsTrack and assist with remediation efforts for Corrective Action Plans related to all audit findingsEnsure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for OperationsTrack all Compliance required training on a yearly and new hire basis for OperationsAssist with all readiness activities in relation to implementation of a new line of business for Operations
Perform any other job-related instructions, as requested
Education and Experience:Bachelor's degree or equivalent years of relevant work experience requiredMinimum of two (2) years of healthcare operations environment is requiredRegulatory and/or compliance experience is preferred
Competencies, Knowledge and Skills:Advanced level experience in Microsoft Word, Excel and PowerPointData analysis and trending skillsDemonstrated understanding of claims operations specifically related to managed careAdvanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS codingAbility to work independently and within a team environmentAttention to detailFamiliarity of the healthcare fieldCritical listening and thinking skillsNegotiation skills/experienceStrong interpersonal skillsProper grammar usageTechnical writing skillsTime management skillsStrong communication skills, both written and verbalCustomer service orientationDecision making/problem solving skills
Licensure and Certification:None
Working Conditions:General office environment; may be required to sit or stand for extended periods of time
Compensation Range:$60,300.00 - $96,500.00 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:SalaryCompetencies:- Create an Inclusive Environment- 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 inclusive environment that welcomes and supports individuals of all backgrounds.