Offer summary

Qualifications:

Bachelor's degree or equivalent work experience required., Minimum of seven years in a healthcare payer organization, preferably in Medicare Advantage or Medicaid., Experience in medical benefit plan design and claims processing is required., Previous supervisory or management experience is essential..

Key responsabilities:

Oversee implementation of new products and benefit requirements with high accuracy.

Manage end-to-end BC&S implementations and document best practices.

Partner with business leaders to ensure compliance and accuracy of plan designs.

Develop reports for data analysis to assist with issue resolution and manage departmental workflows.

Job description

Job Summary:

The Manager, BC & S Implementations is responsible to oversee implementation of all new products and LOBs for the development of benefit requirements and supporting code sets and execute within the appropriate timeframes and deadlines with highest level of accuracy.

Essential Functions:

Responsible for managing the creation, scoping, planning, prioritization, and delivery of all BC&S implementation work for the organization
Manage the end-to-end BC&S implementations by participating in discovery sessions, creating global design decisions, and documenting best practices for coding structures
Partner with key business partners (Market and Product leadership, Regulatory partners, Configuration, Utilization Management, etc.) to ensure accuracy of plan designs and covered services
Responsible for all performance management activities for direct reports, including but not limited to mentoring, coaching, training, holding to performance metrics, quality standards, etc.
Ensure designed member benefits are compliant with all regulations across all product lines (Essential Health Benefits, CMS requirements, mental health parity, etc.)
Manage departmental workflow for design, maintenance, and inquiries
Partner with market and analytics teams to ensure necessary information is available to evaluate benefits and drive optimization
Serve as departmental liaison on BC&S needs of the organization
Resolve resource capacity constraints to ensure deadlines are met
Develop and utilize reports to analyze data to assist with issue resolution and impact analysis
Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of business partners
Manage the Audit and Process team and functions
Collaborate with Team Leads to resolve conflicts of audit result rebuttals
Develop and document departmental processes and workflows
Perform any other job duties as requested

Education and Experience:

Bachelor's degree or equivalent years of relevant work experience is required
Minimum of seven (7) years of experience in a healthcare payer organization required, preferably in Medicare Advantage, Medicaid, and/or Health Insurance Exchange settings
Medical benefit plan design, medical policy development, claims processing and/or configuration experience in Facets or equivalent system is required
Previous supervisory or management experience is required

Competencies, Knowledge, and Skills:

Understanding of CPT, HCPCs, ICD-CM and Revenue codes
Deep and broad understanding of claims processing lifecycle
High level understanding of end-to-end health plan operations and interdependencies
Claims administration system knowledge/training preferred
Understanding of prospective and alternative payment methodologies preferred
Ability to lead process development and improvement and change management
Advanced proficiency with Microsoft Suite to include Word, Excel, and PowerPoint
Excellent problem-solving skills with attention to detail
Project management skills preferred
Auditing skills
Strong service orientation and consulting skills
Highly developed communication skills (written and verbal)
Proven ability to work collaboratively with all levels of management and external stakeholders
Proven ability to juggle multiple, complex priorities within a changing environment
Ability to develop, prioritize and accomplish goals

Licensure and Certification:

None

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time
May be required to travel less than 25% of the time

Compensation Range:

$92,300.00 - $161,600.00

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. 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 Type (hourly/salary):

Salary

Organization Level Competencies