Claims Process Expert Sr. - Ohio MyCare

About the position Claims Process Expert Sr. - Ohio MyCare Location: Candidates are required to live in Ohio. This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The MyCare Ohio Plan program is to deliver high‐quality, trauma informed, culturally competent, person‐centered coordination for all members that addresses physical health, behavioral health, long term services and supports, and psychosocial needs. The Claims Process Expert Sr. oversees the administration of claims processing and operational support functions to ensure compliance with the regulatory standards of Anthem’s Ohio Medicaid products. Works with Provider Experience to research provider inquiries for possible configuration and rate related claims errors, and responsible for ensuring claims resolution success. Also responsible for adhering and reporting against State Prompt Pay and Claims Issue reporting requirements. How you will make an impact Primary duties may include, but are not limited to: Oversee the end-to-end claims process, including receipt, adjudication, payment, and performance reporting on claims timeliness, accuracy, backlog and provider payment compliance. Serve as the operational liaison with the state of Ohio, Provider Experience, and internal executive leadership. Researches operations workflow problems and system irregularities. Develops, tests, presents process improvement solutions for new systems, new accounts and other operational improvements. Develops and leads project plans and communicates project status, Provides process direction and decision making for all minor and major project work. Provides guidance to process experts. May perform duties as a lead when involved with enterprise wide initiatives/projects.

Responsibilities

• Oversee the end-to-end claims process, including receipt, adjudication, payment, and performance reporting on claims timeliness, accuracy, backlog and provider payment compliance.
• Serve as the operational liaison with the state of Ohio, Provider Experience, and internal executive leadership.
• Researches operations workflow problems and system irregularities.
• Develops, tests, presents process improvement solutions for new systems, new accounts and other operational improvements.
• Develops and leads project plans and communicates project status
• Provides process direction and decision making for all minor and major project work.
• Provides guidance to process experts.
• May perform duties as a lead when involved with enterprise wide initiatives/projects.

Requirements

• Requires a BA/BS and minimum of 8 years experience in business analysis, process improvement, project coordination in a high-volume managed care operation (claims, customer service, enrollment and billing); or any combination of education and experience, which would provide an equivalent background.

Nice-to-haves

• Ability to analyze workflows, processes, supporting systems and procedures and identifying improvements strongly preferred.
• Experience with Dual Products: Medicaid and Medicare strongly preferred.
• Ohio state regulatory reporting experience preferred.
• Broad experience in claims Medicaid and/or Medicare within the state of Ohio is strongly preferred.

Benefits

• In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

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