• Claims Operations Specialist III

    Insight Global (Dayton, OH)


    Job Description

    An employer in the Dayton, OH area is seeking a Claims Operations Specialist III for a direct-hire opportunity. This person will be providing analytical support and leadership for Claims related projects for an enterprise level managed care organization. Their main responsibilities will be to serve as a high dollar claims reviewer and keep up regulatory reporting such as CMS and Medicaid Prompt Pay. They also will be tasked with identifying payment integrity issues with claims reimbursement methodologies and provide claims SME for cross-functional meetings including operational and new business implementation. This person will act as the primary claims representative and SME for corporate projects as well as external audits, and lead claims initiatives such as working with IT and other to automate claim functions.

     

    We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to Human Resources Request Form (https://airtable.com/app21VjYyxLDIX0ez/shrOg4IQS1J6dRiMo) . The EEOC "Know Your Rights" Poster is available here (https://www.eeoc.gov/sites/default/files/2023-06/22-088\_EEOC\_KnowYourRights6.12ScreenRdr.pdf) .

     

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    Skills and Requirements

     

    Bachelor's Degree or equivalent years of relevant work experience required

     

    5+ years experience in healthcare claims environment, equivalent managed care, healthcare operations or professional industry experience is required

     

    Experience with Facets as a claims processing software Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding

    Experience processing high dollar claims from $500k-1mil null

    We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal employment opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment without regard to race, color, ethnicity, religion,sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military oruniformed service member status, or any other status or characteristic protected by applicable laws, regulations, andordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or the recruiting process, please send a request to [email protected].