Encounters Systems Analyst II

Job Summary:

The Encounters Systems Analyst II is responsible for performing analysis of Encounters data and understanding the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements are achieved.

Essential Functions:

Perform analysis of Encounter data.  Understand the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements (SLAs) are achieved

Support for Regulatory Data projects

Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes

Support for Claims Encounter Subject Matter Expertise (SME) for both CMS and State agencies and internal CareSource impacted organizations (IT, Claims, New Business, Enrollment, etc.)

Build, sustain and leverage relationships with persons within his/her area of responsibility to allow for continuous improvement of the Encounter Data business process

Support for testing and delivering process to business.

Participate in claims data processes to ensure accuracy and compliance with CMS and state agencies

Participate in the key claims data management and readiness to state and governing entities

Understand the Claims Encounter Data requirements in detail to enable one to support efforts to ensure claims data submissions achieve the required SLAs through requested changes internally and externally

• Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies
• Support Claims Encounters regulatory reporting
• Support for critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
• Monitor various management and oversight metrics and reports as required

Support Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with reporting department

• Provide support of vendors, managing SLA’s, regulatory requirements and contractual metrics
• Maintain positive and strategic relationships with internal and external stakeholders
• Contribute to and/or develop user stories or provide user story guidance for sprint planning

Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLA’s

Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in Science/Arts or equivalent years of relevant work is required
• Master’s Degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred
• Minimum of one (1) year to two (2) years of managed healthcare, claims, or managed care regulated environment experience is required
• Minimum of one (1) year of experience using at least two of the following tools is required:  SQL, SAS, SSIS. MySQL, ORACLE, R, or PowerBI

Competencies, Knowledge and Skills:

• Intermediate computer skills, Advanced skills in Excel
• Edifecs knowledge is preferred
• Data analysis and trending skills
• Demonstrated understanding of claims operations specifically related to encounters
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
• Knowledge of Claims IT processes/systems and analytic processes
• Knowledge of Agile is preferred
• Knowledge of Facets is preferred
• Experience in Documentation of business requirements
• Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
• Experience with 837O files to States and/or CMS (MA EDS) preferred
• Experience with 835 files preferred
• Excellent communication skills; both written and verbal required
• Ability to work independently and within a team environment
• Time management skills; capable of multi-tasking and prioritizing work
• Attention to detail
• Effective decision making / problem solving skills
• Critical thinking and listening skills

Licensure and Certification:

None

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time