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Director, Provider and Member Configuration

Company: CareSource
Location: Dayton
Posted on: October 14, 2020

Job Description:

Requisition Number 20-0881 Post Date 8/25/2020 Title Director, Provider and Member Configuration City Dayton State OH DescriptionRole and Responsibility:


  • Lead the analysis, design, development, testing and implementation of the company's Facets and clinical editing systems; provide application support during advanced stages of implementation

  • Direct and lead configuration activities of a highly technical team by providing coaching and mentoring with a focus on quality, efficiency and collaboration; provide guidance in resolving technical issues

  • Direct database configuration activities intended to modify and enhance the company operational database; activities include database set-up of product benefits, fee schedules, claims edits, provider agreements and claims processing rules

  • Lead automation and upgradation efforts for Facets and clinical editing systems

  • Responsible for proactive analysis of internal operational, service and performance metrics, and proactively initiate performance improvement activities across the organization to achieve service and satisfaction goals

  • Create technical design and provide technical oversight to ensure the proper architecture and product performance is delivered; create architectural design and technical design documents

  • Ensure appropriate approvals, testing, implementation controls and validation occur relative to new or modified records and files

  • Develop and maintain departmental policies, procedures and controls to ensure the integrity of the files, including HIPAA compliance

  • Initiate and implement automated solutions to ensure optimal data quality
  • Ensure that all policies and procedures are in place, are up to date, are consistent across department and CareSource and are compliant with all legal, Federal, State and Accrediting standards

  • Ensure compliance with Model Audit Rules, State, Federal and Accrediting Agencies for all elements related to systems configuration data and processes

  • Participate in national conferences and other events to stay current with industry changes

  • Provide direction in the development of best practices configuration strategies to meet corporate goals related to operational efficiencies and excellence

  • Work with business owners to achieve a system design that meets their needs and expectations

  • Ensure that supporting business processes and documentation exists as a basis for system logic

  • Play a consultative role with business owners around configuration, benefits, fee schedules, provider appeals related to claims, etc.

  • Perform any other job related instructions as requested

    RequirementsEducation / Experience:


    • Bachelor's degree or equivalent years of relevant work experience is required

    • Master's degree is preferred
    • A minimum of five (5) years of health plan business or systems solutions experience is required

    • Minimum of three (3) years of management experience is required
    • Facets experience is preferredRequired Competencies / Knowledge / Skills:


    • Proficient in Microsoft Office Suite to include Word, Excel, Access and Outlook

    • Familiarity of the healthcare field
    • High level of database and systems development knowledge
    • Ability to translate business requirements into technical specifications
    • Ability to manage and prioritize multiple tasks, promote teamwork and fact based decision

    • Strong team and staff development skills
    • Strong collaboration and conflict resolution skill sets
    • Proven leadership with the ability to build relationships, collaborate and influence at all levels

    • Strong process and analytical skills with the ability to articulate and define outcome measures that capture key performance metrics

    • Strategic management skills
    • Resiliency in a changing environment
    • Strong decision making and problem solving skills
    • Exceptional written and verbal communication skills with the ability to present information in a variety of different formats to all levels Strong interpersonal skills and high level of professionalism

    • Effective listening and critical thinking skills
    • Display a customer service orientation
    • Ability to develop, prioritize and accomplish goals
    • Excellent problem solving skills with attention to detailLicensure / Certification:


    • Six Sigma certificate or Training preferredWorking Conditions:







      • General office environment; may be required to sit/stand for long periods of time

      • Ability to travel as required by the needs of 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, including disability and veteran status. We are committed to a diverse and inclusive work environment.

Keywords: CareSource, Dayton , Director, Provider and Member Configuration, Executive , Dayton, Ohio

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