We are actively seeking a highly motivated, innovative and experienced individual to join our team as the Manager of Claims & Encounter Analytics and Reporting. Compensation will be commensurate with experience.
Position Summary:The Manager of Claims & Encounter Analytics and Reporting is responsible for overseeing the end-to-end encounter management process between the Health Plan and its vendors, ensuring accurate, timely, and compliant encounter submission and reconciliation. Working closely with the Director of Claims and Encounters, this role develops and maintains claims analytics, auditing, dashboards, and regulatory reporting while leading projects that support operational excellence, data integrity, and continuous process improvement.
Responsibilities:- Responsible for documenting, monitoring, and analyzing the end-to-end encounter life cycle, both inbound and outbound. This work includes keen oversight of Amida Care's TPA/Vendor Encounter Process and Vendor Encounter Submissions, being Amida Care's primary liaison with the NYS APD/OSDS Unit.
- Perform root cause analysis of claims/encounters processing and submission issues; communicate with management and recommend opportunities for improvement.
- Research and document all encounter errors; perform encounter data reconciliation and statistical trend analysis.
- Ensure the accuracy of claims processing and payments while meeting company standards of quality by auditing claims to identify process improvement opportunities.
- Analyzes and documents audit results by tracking and trending audit results.
- Create business requirements, conduct UAT testing and support implementation of changes.
- Write specifications for the advancement of present reports on various areas of claims inventory (denials, pends, appeals etc.). Reports will be created with collaborative efforts and geared to the specific end users.
- Develop reports to evaluate volume trends, financial trends and any other outside variables which affect claim behaviors and industry KPIs (Key Performance Indicators).
- Support the Direct of Claims and Encounter Reporting with analytics and reporting centering on new and current reimbursement methodologies, claims reporting and general industry changes.
- Partner with the Manager of Reimbursement to create, implement and maintain internal claims and contract configuration audits.
- Support Regulatory reporting and analytics as needed.
- Perform other duties as assigned.
EDUCATION REQUIRED- Bachelor's Degree or an equivalent combination of education and related experience.
EXPERIENCES AND/OR SKILLS REQUIRED- Minimum of five (5) years' experience in Medicaid Regulatory reporting and or Claims/ Encounters.
- Minimum of five (5) years' experience in a health plan environment.
- Strong analytical and organizational skills.
- Advanced proficiency in Microsoft Office software (Word, Access, and Excel).
- Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
- Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values.
