[Hiring] Claims Reimbursement Analyst II @CareSource

Role Description

The Claims Reimbursement Analyst II is responsible for performing reimbursement analysis to support accurate claims payment, contract compliance, and operational efficiency. This role focuses on analytical review of reimbursement outcomes, identification of payment variances, and support of configuration, testing, and process improvement efforts.

• Develop, implement, and maintain reimbursement guidelines for assigned CareSource products.
• Collaborate with product owners and cross-functional partners to align reimbursement processes with organizational strategy.
• Support Benefit Interpretation activities using applicable grids, spreadsheets, and technology-based applications.
• Conduct legislative, regulatory, reimbursement material, and internal control reviews for compliance.
• Analyze reimbursement outcomes, payment data, and implementation results to identify discrepancies and trends.
• Perform root-cause analysis, document findings, recommend corrective actions, and support issue resolution.
• Prepare and execute user acceptance testing and validate configuration and reimbursement logic.
• Use reporting, query, automation, AI-enabled, and other technology-based tools to improve Claims accuracy.
• Develop recurring, ad hoc, and required reports for internal stakeholders and external governing bodies.
• Identify and manage risks, implement mitigation strategies, and communicate concerns to stakeholders.
• Lead and participate in initiatives and team meetings, establishing and executing detailed tasks.
• Support established budgets, timelines, milestones, and task schedules.
• Provide guidance, support, and training to Claims and Operations.
• Leverage automation and AI-enabled tools to identify reimbursement trends and improvement opportunities.
• Perform any other job-related duties as requested.

Qualifications

• Bachelor's degree in Business, Healthcare Administration, Finance, Analytics, or a related field required.
• Equivalent years of relevant work experience may be accepted in lieu of required education.
• Three (3) years of product management, reimbursement policy creation, or claims experience required.
• Two (2) years of experience in healthcare reimbursement, claims analysis, or payment operations required.
• Familiarity with the healthcare/managed care field and knowledge of government program products required.
• Previous experience working with state and federal regulators/government in a managed care setting preferred.

Requirements

• Working knowledge of healthcare reimbursement, claims processing, and provider contracting concepts.
• Strong analytical, critical thinking, and problem-solving skills.
• Ability to translate analytical findings into clear documentation and actionable recommendations.
• Proficiency with claims systems, reporting tools, data analysis applications, and Microsoft Office Suite.
• Understanding of regression, unit, and user acceptance testing methodologies.
• Familiarity with payment methodologies and industry pricers (e.g., DRG, APC, SNF, RBRVS) preferred.
• Strong written and verbal communication skills.
• Demonstrated ability to work independently and collaboratively in a fast-paced environment.
• Customer service mindset with a strong member and provider focus.
• Decision making/problem solving skills with a demonstrated ability to execute.

Benefits

• Compensation Range: $62,700.00 - $100,400.00.
• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• Comprehensive total rewards package focused on employee well-being.

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time.
• Travel is not typically required.

Licensure and Certification

• None.

Company Description

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.