Operations Regulatory Specialist II (Hybrid location)
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$63k–$100k/yr
Full-time
bachelor degree
Bonus, Total Rewards Package
Posted 88d ago
~40 hrs/week
Responsibilities
Provides analytical support and leadership for internal operations projects to ensure regulatory and compliance deliverables are met. Responsibilities include monitoring IT tickets, drafting policies and procedures, and performing claims data analysis for regulatory requests.
Requirements
Requires a bachelor's degree or equivalent experience and at least two years of experience in a healthcare operations environment. Proficiency in Microsoft Office and knowledge of medical coding (CPT, ICD-9, ICD-10, HCPCS) are essential.
Full job description
Job Summary:
The Operations Regulatory Specialist II provides analytical support and leadership for key internal Operations projects and partners with the Operations departments to ensure all regulatory and compliance deliverables are met. This position will work Tues/Thurs in the Dayton, Ohio office and remote the other days.
Essential Functions:
Represent operations on cross-functional project work teams
Submit, monitor and prioritize IT tickets for the operations departments
Review special projects and identify issue trends and potential resolutions
Assist with reporting and processes that are regulatory related and tied to state issues deadlines
Assist with the development, drafting and review of P&P’s and job aides for Operations
Assist in educating/training Business Partners on operations functions.
Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include:
Documentation gathering – i.e. review of Standard Operating Procedure and/or Policy and Procedure to the audit/inquiry requirements
Audit Universe monitoring and/or creation – collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submission
Prepare Operations Business Owners for live questions and answers with the state regulators or auditors
Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
Track all Compliance required training on a yearly and new hire basis for Operations
Assist with all readiness activities in relation to implementation of a new line of business for Operations
Perform any other job-related instructions, as requested
Education and Experience:
Bachelor’s degree or equivalent years of relevant work experience required
Minimum of two (2) years of healthcare operations environment is required
Regulatory and/or compliance experience is preferred
Competencies, Knowledge and Skills:
Advanced level experience in Microsoft Word, Excel and PowerPoint
Data analysis and trending skills
Demonstrated understanding of claims operations specifically related to managed care
Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field
Critical listening and thinking skills
Negotiation skills/experience
Strong interpersonal skills
Proper grammar usage
Technical writing skills
Time management skills
Strong communication skills, both written and verbal
Customer service orientation
Decision making/problem solving skills
Licensure and Certification:
None
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$62,700.00 - $100,400.00
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
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
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.
Health Care with Heart. It is more than a tagline; it’s how we do business. CareSource has been providing life-changing health care to people and communities for 30+ years and we continue to be a transformative force in the industry by placing people over profits.
CareSource is and will always be member-first. Even as we grow, we remember the reason we are here – to make a difference in our members’ lives by improving their health and well-being. Today, CareSource offers a lifetime of health coverage to more than 2 million members through plan offerings including Marketplace, Medicare products and Medicaid. With our team of 4,500+ employees located across the country, we continue to clear a path to better life for our members. Visit the "Life" section to see how we are living our mission in the states we serve.
CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law. If you’d like more information about your EEO rights as an applicant under the law, please click here: https://www.eeoc.gov/employers/upload/poster_screen_reader_optimized.pdf and here: https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_EEO_Supplement_Final_JRF_QA_508c.pdf
Offices: Dayton, OH, US
MedicaidHealth Insurance MarketplaceHealth InsuranceLTSSand Health CareHealth CareNon ProfitMedical
How many Healthcare jobs are open in Dayton, OH right now?
There are currently 874 open healthcare positions in Dayton, OH listed on Clera. New openings are added daily as companies post roles.
Which companies are hiring for Healthcare roles in Dayton, OH?
Companies currently hiring include Premier Health Partners, Kettering Health, Dayton Children's Hospital, Ohio's Hospice, CareSource, among others. Browse the listings above to see every active employer.
Are there remote or hybrid Healthcare jobs in Dayton, OH?
Yes — 95 of the 874 open healthcare positions offer remote or hybrid work (58 remote, 37 hybrid).
How do I apply for Healthcare jobs in Dayton, OH?
Each listing links directly to the employer's application page. Apply early — fresh listings get the most recruiter attention in the first two weeks.