Qureos Mentor

CareSource

CareSource is a health care organization that provides a range of health insurance plans, including Medicaid, Medicare, and Marketplace options. They focus on delivering comprehensive health services tailored to the needs of individuals and families, including low-income adults, children, and those with disabilities. CareSource emphasizes member support through their digital platform, CareSource MyLife, which helps users manage their health plans and access necessary resources.

<div>Job Summary:
The Program Integrity Medical Coding Reviewer III generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes.
Essential Functions:<ul><li>
Provide Provider Pre Pay production and progress reports and coordinate with management and team on recommendation for further actions and/or resolutions in order to increase team performance</li><li>
Recommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gaps</li><li>
Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts to identify and perform oversight and monitoring of claims decisions based on documentation.</li><li>
Identify knowledge gaps and provide training opportunities to team members</li><li>
Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWA</li><li>
Identify and assist in correction of organizational workflow and process inefficiencies</li><li>
Serve as the primary resource for provider pre-pay team</li><li>
Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions</li><li>
Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines</li><li>
Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirements</li><li>
Responsible for making claim payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policies</li><li>
Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business</li><li>
Responds to claim questions and concerns</li><li>
Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed</li><li>
Possess a general knowledge and understanding of CareSource claim payment edits</li><li>
Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims</li><li>
Build strong working relationships within all teams of Program Integrity</li><li>
Work under limited supervision with considerable latitude for initiative and independent judgement</li><li>
Perform any other job related instructions as requested</li></ul>
Education and Experience:<ul><li>
Associate&rsquo;s degree or equivalent years of relevant work experience is required</li><li>
Minimum of five (5) years of medical billing and coding experience to include minimum of three (3) years of SIU/FWA medical billing and coding experience is required</li><li>
Prior experience with claim pre-payment, medical claim and documentation auditing required</li><li>
Medicaid/Medicare experience is required</li><li>
Minimum of three (3) years of experience in Facets is preferred</li><li>
Experience with reimbursement methodology (APC, DRG, OPPS) is required</li><li>
Inpatient coding experience is preferred</li><li>
Leadership experience is preferred</li></ul>
Competencies, Knowledge and Skills:<ul><li>
Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines</li><li>
Thorough understanding of medical claim configuration</li><li>
Clinical or medical coding background with a firm understanding of claims payment</li><li>
Proficient in Microsoft Office Suite</li><li>
Firm understanding of basic medical billing process</li><li>
Excellent written and verbal communication skills</li><li>
Ability to work independently and within a team environment</li><li>
Effective problem solving skills with attention to detail</li><li>
Knowledge of Medicaid/Medicare and familiarity of healthcare industry</li><li>
Effective listening and critical thinking skills</li><li>
Ability to develop, prioritize and accomplish goals</li><li>
Strong interpersonal skills and high level of professionalism</li></ul>
Licensure and Certification:<ul><li>
Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire</li></ul>
Working Conditions:<ul><li>
General office environment; may be required to sit or stand for extended periods of time</li></ul>
Compensation Range:
$62,700.00 - $100,400.00
CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;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&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
<ul><li>Fostering a Collaborative Workplace Culture</li><li>
Cultivate Partnerships</li><li>
Develop Self and Others</li><li>
Drive Execution</li><li>
Influence Others</li><li>
Pursue Personal Excellence</li><li>
Understand the Business</li></ul><h2 class="jobSectionHeader"> 
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. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.</h2>
#LI-SD1</div>

PI Medical Coding Reviewer III (CPC, RHIT or RHIA required)

<div>Job Summary: 
 
The Team Lead, Customer Care is responsible for leading and directing their team to ensure goals, regulatory, compliance, and department standards are met. 
 
Essential Functions:<ul><li>
Conduct regularly scheduled coaching conversations; listening and providing feedback for improved performance, and when applicable, create performance improvement plans</li><li>
Properly document coaching and development conversations in HR system</li><li>
Complete performance appraisals; write appropriate corrective actions, when needed</li><li>
Conduct monthly team meetings and huddles to inform, drive, and foster an environment of team building and allow for ongoing communications</li><li>
Analyze and leverage data to make recommendations, decisions and improve team performance</li><li>
Monitor key operational performance indicators on a daily, weekly, monthly basis to identify key trends and develop action plans that address opportunities</li><li>
Identify processes, tools, systems, and behaviors that cause negative impact on efficiency and customer service results, leading to continuous improvement solutions</li><li>
Build positive relationships and interactions with internal peers, leaders, and cross functional partners through strong follow through and communication</li><li>
Promote positive change management</li><li>
Facilitate timely resolution of member, provider, corporate, compliance, and any other tasks requiring deadlines</li><li>
Implement, enforce, and support company and departmental policies and procedures</li><li>
Maintain a deep understanding and stay informed on business, new product, tools, processes, etc</li><li>
Monitor and evaluate calls for quality, compliance, efficiency, and customer satisfaction purposes; actively participate in the internal quality program</li><li>
Conduct interviews and evaluate candidates for hiring purposes</li><li>
Performs any other job related duties as requested</li></ul> 
Education and Experience:<ul><li>
High School or GED required</li><li>
Associates preferred</li><li>
Three (3) years of customer service experience, to include a minimum of one (1) year in a call center environment required</li><li>
One (1) year of outbound call center experience preferred</li><li>
Previous supervisory/leadership experience in a call center environment is strongly preferred</li></ul>
Competencies, Knowledge and Skills:<ul><li>
Intermediate proficiency level in MS Word, Excel and PowerPoint</li><li>
Ability to communicate verbally and in written form with a variety of levels within organization</li><li>
Ability to work independently and within a team environment</li><li>
Familiarity of the healthcare field and knowledge of Medicaid or Medicare is preferred</li><li>
Attention to detail</li><li>
Critical listening and thinking skills</li><li>
Coaching and development skills</li><li>
Strategic management skills</li><li>
Proper grammar usage</li><li>
Time management skills</li><li>
Conflict resolution skills</li><li>
Customer service oriented</li><li>
Leadership experience and skills</li><li>
Critical listening and thinking skills</li><li>
Decision making/problem solving skills</li></ul>
Licensure and Certification:<ul><li>
None required</li></ul>
Working Conditions:<ul><li>
General office environment; may be required to sit or stand for extended periods of time</li><li>
Travel is not typically required</li></ul>
Compensation Range:
$54,500.00 - $87,300.00
CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;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&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies<ul><li>
Fostering a Collaborative Workplace Culture</li><li>
Cultivate Partnerships</li><li>
Develop Self and Others</li><li>
Drive Execution</li><li>
Influence Others</li><li>
Pursue Personal Excellence</li><li>
Understand the Business</li></ul><h2 class="jobSectionHeader"> 
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. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.</h2>
#LI-KM1</div>

Team Lead, Customer Care

<div>Job Summary: 
 
The FWA Payment Integrity Data Analyst III is responsible for developing, implementing, managing and presenting in-depth analyses that meet the information needs associated with Fraud, Waste and Abuse. 
 
Essential Functions:<ul><li>
Lead and implement data analytic Ideation and R&amp;D activities and strategy to support decision-making across multiple lines of business and clients to enable FWA growth.</li><li>
Validate Program Integrity vendor deliverables, results and collaborate with PI vendors to understand and drive CareSource FWA analytic needs and results, function as consultant to propose business solutions, and communicate results of data analytics outcomes against goals and strategic plan.</li><li>
Participate in analytical, experimental, investigative, and other fact-finding work in support of concept development and in conjunction with vendors.</li><li>
Monitor emerging internal and external FWAE data vulnerabilities and trends which may impact CareSource and create solutions to mitigate risk.</li><li>
Identify trends and patterns using standard corporate, processes, tools, reports, and databases as well as leveraging other processes and data sources</li><li>
Research policies, coding guidelines, and regulations that would support the hypothesis being developed.</li><li>
Conduct outcome analyses to determine impact and effectiveness of corporate and SIU initiatives.</li><li>
Collaborate on the examination and explanation of complex data relationships to answer questions identified either within the department or by other departments as it relates to Fraud Waste and Abuse.</li><li>
Generate graphics that effectively describe, explore, and summarize analysis for communication to appropriate parties.</li><li>
Manage processes and reporting to ensure that claims associated with investigations are processed appropriately and in a timely manner.</li><li>
Collaborate with the Legal Department, generating data and analyses to support Legal proceedings.</li><li>
Perform data analyses in support of both the SIU Program Integrity and Audit Functions.</li><li>
Incorporate critical thinking skills and judgment in the analysis process to determine best course of action for each inquiry/problem.</li><li>
Review reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques that will reveal intelligence for identification of any associative or causal relationships pertaining to Fraud Waste and Abuse and Error, providing management level summaries that explain key findings and providing documentation for use during Audits.</li><li>
Use descriptive statistical techniques to measure impact of various actions/studies, internal and external, develop sampling and hypothesis testing to help the organization determine outcomes.</li><li>
Performs any other job related duties as requested.</li></ul> 
Education and Experience:<ul><li>
Bachelor's degree or equivalent years of relevant work experience in Healthcare Data Analytics required</li><li>
Seven (7) years of experience in data analysis, FWA Ideation and/or analytic programming required</li><li>
Seven (7) years Health care delivery and/or payer experience required</li><li>
Extensive experience with Data Visualization / Dashboard tools (Power BI) required</li><li>
Extensive experience using SQL for analytics projects, including databases queries required</li><li>
Three (3) years of experience with Medicare/Medicaid required</li><li>
Healthcare management experience/exposure required</li><li>
Clinical experience is preferred</li></ul>
Competencies, Knowledge and Skills:<ul><li>
Proven understanding of database development including: Implementing Database Relationships; Data Integration; Data Manipulation using SQL; Database Object Creation using SQA; Database Normalization; Dimensional Design Concepts</li><li>
Insight in administering Microsoft SQL Server, Transact-SQL (ANSI-SQL) and Integration Services (SSIS) is required</li><li>
Insight and understanding of in programming languages such as Microsoft Visual Basic, Python</li><li>
Strong Knowledge of coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and DRGs)</li><li>
Proven analytic skills in solving multi-dimensional problems</li><li>
Advanced level experience in Microsoft Applications: Excel, Access, Word, and PowerPoint</li><li>
SAS and SQL skills</li><li>
Graphic development/presentation skills</li><li>
Knowledge of inferential statistics</li><li>
Working knowledge of descriptive statistical application and techniques</li><li>
Data Mapping Skills</li><li>
Ability to document database design, application design</li><li>
Ability to maintain documentation of changes and modifications</li><li>
Critical listening, thinking skills, and verbal and written communication skills</li><li>
Decision making/critical thinking skills</li><li>
Ability to work independently and within a team environment</li><li>
Knowledge of Medicaid, Medicare, and managed care</li><li>
Ability to lead analytic efforts</li></ul>
Licensure and Certification:<ul><li>
Coding certification through AAPC or AHIMA preferred</li></ul>
Working Conditions:<ul><li>
General office environment; may be required to sit or stand for extended periods of time</li><li>
Travel is not typically required</li></ul>
Compensation Range:
$83,000.00 - $132,800.00
CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;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&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
<ul><li>Fostering a Collaborative Workplace Culture</li><li>
Cultivate Partnerships</li><li>
Develop Self and Others</li><li>
Drive Execution</li><li>
Influence Others</li><li>
Pursue Personal Excellence</li><li>
Understand the Business</li></ul><h2 class="jobSectionHeader"> 
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. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.</h2>
#LI-SD1</div>

FWA Payment Integrity Data Analyst III

<div>
 
 Job Summary
 
 
 
 The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
 
 
 
 Essential Functions
 
 
 
 <ul>
 <li>
 Responsible for the completion of clinical appeals and state hearings from all states
 </li>
 <li>
 Perform clinical reviews of member and provider appeals for medical, dental, behavioral health, pharmacy, and waiver services
 </li>
 <li>
 Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
 </li>
 <li>
 Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards
 </li>
 <li>
 Work closely with medical directors, and pharmacists to resolve complex cases.
 </li>
 <li>
 Communicate outcomes effectively to members, and providers.
 </li>
 <li>
 Review and complete all provider clinical appeals within required timeframes
 </li>
 <li>
 Review and complete member clinical appeals within required timeframes
 </li>
 <li>
 Communicate with state agencies and internal departments to prepare for State Hearings
 </li>
 <li>
 Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
 </li>
 <li>
 Issue administrative denials appropriately
 </li>
 <li>
 Refer denials based on medical necessity to medical director
 </li>
 <li>
 Collaborate with the Quality Improvement and Clinical Operations teams to prepare all requests for Independent External Review
 </li>
 <li>
 Participate in training programs to maintain clinical and regulatory expertise.
 </li>
 <li>
 Perform any other job duties as requested
 
 
 </li>
 </ul>
 
 Education And Experience
 
 
 
 <ul>
 <li>
 Associate&rsquo;s Degree required
 </li>
 <li>
 Managed care, appeals, Medicare, and Medicaid experience preferred
 </li>
 <li>
 Prior clinical appeals, and/or Utilization review experience is strongly preferred
 
 
 </li>
 </ul>
 
 Competencies, Knowledge And Skills
 
 
 
 <ul>
 <li>
 Intermediate proficiency with Microsoft Office products and Facets
 </li>
 <li>
 Knowledge of NCQA, URAC, OAC, and MDCH regulations
 </li>
 <li>
 Strong clinical judgment
 </li>
 <li>
 Attention to detail
 </li>
 <li>
 Ability to navigate complex regulations while maintaining a commitment to high-quality care
 </li>
 <li>
 Strong written and oral communication skills
 </li>
 <li>
 Ability to work independently and within a team environment
 </li>
 <li>
 Critical listening and thinking skills
 </li>
 <li>
 Proper grammar usage
 </li>
 <li>
 Time management skills
 </li>
 <li>
 Proper phone etiquette
 </li>
 <li>
 Customer Service oriented
 </li>
 <li>
 Decision making/problem solving skills
 </li>
 <li>
 Knowledge of Medicaid, and Medicare,
 </li>
 <li>
 Flexibility
 </li>
 <li>
 Change resiliency
 
 
 </li>
 </ul>
 
 Licensure And Certification
 
 
 
 <ul>
 <li>
 Current, unrestricted license as a Registered Nurse (RN) is required
 </li>
 <li>
 Multi-state RN license is preferred
 </li>
 <li>
 MCG Certification is required or must be obtained within six (6) months of hire
 
 
 </li>
 </ul>
 
 Working Conditions
 
 
 
 <ul>
 <li>
 General office environment; may be required to sit or stand for extended periods of time
 </li>
 <li>
 Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
 
 
 </li>
 </ul>
 
 Compensation Range
 
 
 
 $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;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&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
 
 
 
 Compensation Type
 
 
 
 Hourly
 
 
 
 Competencies
 
 
 
 <ul>
 <li>
 Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
 
 
 </li>
 </ul>
 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. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
 
 
</div>

Clinical Appeals - R11356

Join CareSource and explore 4   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

CareSource

About Company

PI Medical Coding Reviewer III (CPC, RHIT or RHIA required)

Team Lead, Customer Care

FWA Payment Integrity Data Analyst III

Clinical Appeals - R11356