Sr. Claims SME

at  Clearlink Partners

COMPANY DESCRIPTION:

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.
We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

POSITION QUALIFICATIONS:

Competencies:

• Previous experience with claims, appeals and grievances for multiple lines of business (LOBs) including Medicare Advantage, Managed Medicaid, Dual SNP, & Commercial Lines of Business.
• Knowledge of current insurance benefit structures
• Knowledge and competency with claims payment review, edits and configuration
• Excellent oral and written interpersonal/communication
• Strong internal/external customer-service, organizational, multitasking, and teamwork skills
• Excellent analytical thinking/problem-solving skills
• Proficiency in Microsoft Office
• Ability to work effectively in a fast-paced environment with multiple priorities, deadlines, and workloads

Experience:

• Bachelor’s Degree in Healthcare Administration or related field
• 5+ years progressive leadership experience in health plan operations focused on government payor programs
• 5+ years of experience work for a Managed Care (Payer)

Physical Requirements:

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language

Time Zone: Eastern or Central

Other Information:

• Expected Hours of Work: Friday 8 am – 5 pm ; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None
• Salary Range: $96,000 – $150,000

Specific

• Track and report common source errors or technical issues for evaluation and remediation by product team
• Communicate key insights and findings to product team
• Evaluate ways to improve monitoring, discover issues and deliver better value to the customer
• Provide recommendations for possible process changes to optimize process and maximize performance
• Conduct audits of provider and member work streams to promote compliance, improve experience, optimize outcomes, and ensure high-value procedures are in place
• Investigate potential quality of care complaints, including tracking and trending areas of concern

General

• Maintaining timely and effective internal and external communication regarding assigned work/ tasks
• Logging, tracking, and ensuring completion of all work in compliance with contract service standards
• Tracking review completion of assigned work to ensure final closure/ resolution
• Managing high workload volumes, ensuring accuracy and compliance with contractual deadlines
• Ensuring all necessary information is available and organized for professional staff review/resolution
• Outreach as necessary for clarification or collection of additional information needed
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines