Encounters Systems Analyst III at Caresource in Dayton, OH

Job Summary:

The Encounters Systems Analyst III is responsible for compiling and analyzing Encounters data and understanding the financial and clinical impact of changes and decision to the business process to ensure that Service Level Agreements are achieved.

Essential Functions:

• Compile and analyze 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
• Provide analytical support and leadership for Claims Encounters Regulatory Data projects
• Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes
• Provide 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 responsibility to constantly allow for continuous improvement of the Encounter Data business process
• Direct responsibility for the design, testing and delivery of supporting processes to the business
• Lead the claims data processes to ensure accuracy and compliance with CMS and state agencies
• Provide support for other key claims data management and readiness to state and governing entities
• Understand the Claims Encounter Data requirements in detail to enable one to lead 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
• Responsible for Claims Encounters regulatory reporting
• Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
• Prepare and monitor various management and oversight metrics and reports as required
• Lead Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with SIS
• 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 or equivalent years of relevant work experience is required
• Minimum of five (5) years of managed healthcare, claims, or managed care regulated environment experience is required

Competencies, Knowledge and Skills:

• Knowledge of relational databases (SQL Server, Oracle, etc.)
• Experience with SQL Server - 2016 or newer
• Strong database querying, data analysis and trending skills
• Edifecs knowledge is desired
• Demonstrated understanding of claims operations specifically related encounters
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
• Knowledge of Claims IT processes/systems
• Knowledge of claims analytic processes/systems
• 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
• Ability to work independently and within a team environment
• Time management skills; capable of multi-tasking and prioritizing work
• Attention to detail
• Critical thinking and listening skills

Working Conditions:

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