Sr. Mgr. Claims and Encounters (OHRISE)

Job DescriptionBusiness Overview:As part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.Position Summary :This is a full-time teleworker opportunity; must reside in Ohio. The Claims and Encounters Administrator is responsible for ensuring prompt and accurate provider claims processing and accurate and timely encounter reporting to ODM. Health plan liaison to claims processing and enrollment submission functional areas. The Claims & Encounter Administrator also maintains oversight of functions in local service center, including but not limited to customer service, claim, provider services, complaints, grievances, and appeals, implementation, and/or plan sponsor operations. Executes local strategic and operational plan in support of business segment customer service objectives and initiatives. Plans, directs and implements procedures that will assure a high level of customer access and satisfaction. Responsible for the quality and effectiveness of own team and related teams, identifying and resolving technical, operational and team problems. Fundamental Components: ∙ Plan liaison with segment claims and encounter teams; working cross functionally with operations to resolve claim issues impacting encounter performance to ensure contractual requirements are met. Facilitate performance review meeting with segment claims and encounter teams.∙ Oversees the operations in a local service center handling a customer service function, which may include claims, member or provider services, billing, enrollment, accounts receivable and implementation services.∙ Assist with developing billing guides for various provider types and act as subject matter expert for claim submission requirements to ensure encounter acceptance including provider education and training sessions.∙ Develops, monitors, and reviews performance reports and service performance trends for each account against the plan and recommends specific actions or remedies as necessary.∙ Develops and maintains strong collaborative relationships within operations as well as with patient management, Sales and Marketing, PSS, Underwriting, Utilization Management, and network management in establishing appropriate service level agreements.∙ Creates and maintains tools, job aids, and training materials to help employees in their efforts to resolve issues and improve their relationship with customers.∙ Collects, analyzes and reports on operations information in support of process, systems, and policy redesign.∙ Effectively applies and enforces Aetna HR policies and practices, i.e., FMUEML, Attendance, Code of Conduct, and Disciplinary Guidelines.∙ Effectively manages cross-functional projects that support the business strategy.Specific to the OhioRISE contract, responsibilities include but are not limited to:Develop and implement claims processing systems capable of paying claims in accordance with state and federal requirements, including resubmissions and overall adjudication of claims;Develop processes for cost avoidance;Ensure minimization of claims recoupments;Ensure claims processing timelines are met; andEnsure ODM encounter reporting requirements are met, including sufficient staff to ensure the submission of timely, accurate, and complete encounter data to ODM.Pay RangeThe typical pay range for this role is:Minimum: 75,400Maximum: 158,300Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications-Claims processing experience in a health plan is required.- 5+ years' experience in managing high volume transaction processing, financial management, project delivery, production, systems analysis and application program development. - Demonstrated negotiation skills and problem-solving skills.- Experienced working with vendors.- Customer service experience.- Demonstrated proficiency with personal computer, keyboard navigation skills and with MS Office Suite applications (Outlook, Word, Excel, PowerPoint, SharePoint, etc.)- Ability to travel in-state, as needed. Must have access to reliable transportation.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications-Encounters experience is preferred.- Multiple years proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes.- Previous claim processing and/or encounter submissions.- Healthcare experience preferred; managed care, Medicaid, and Behavioral Health experience is a plus.-Analytical minded.-Provider experience.-Some knowledge of encounter data reporting-Basic knowledge of electronic data interchanges-Strong leadership skills managing high-performance teams.-Exceptional verbal, written, presentation, and interpersonal skills.-Advanced degree preferred.EducationBachelor's degree in a closely related field, or equivalent combination of education and experience.Business OverviewBring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Created: 2025-11-15