Encounters Systems Analyst II

This is a fully remote position, open to applicants in United States.

📋 Description

• Analyze Encounter data to extract insights.

• Assess the financial and clinical implications of modifications and decisions regarding business processes to ensure compliance with Service Level Agreements.

• Assist with Regulatory Data projects.

• Evaluate Encounter rejections and resolve both minor and complex data issues or process modifications.

• Serve as a subject matter expert on Claims Encounter for CMS, state agencies, and internal CareSource teams.

• Establish and utilize relationships to foster continuous enhancement of Encounter Data business processes.

• Aid in the testing and implementation of processes across the business.

• Engage in claims data processes to guarantee accuracy and adherence to CMS and state agency standards.

• Participate in claims data management and ensure readiness for state and governing bodies.

• Support claims data submissions and comply with necessary SLAs through internal and external changes.

• Identify discrepancies and gaps to enhance productivity, precision, data usability, procedures, and policies.

• Assist with regulatory reporting for Claims Encounters.

• Contribute to performance reporting and analysis, suggesting enhancements, cost-saving initiatives, and process improvements.

• Monitor management and oversight metrics and reports.

• Support Claims Encounter initiatives, including automation in collaboration with IT and improvements in regulatory report development.

• Manage vendor relations, ensuring compliance with SLAs, regulatory requirements, and contractual metrics.

• Maintain strategic partnerships with internal and external stakeholders.

• Contribute to or create user stories and provide guidance for user stories during sprint planning.

• Utilize knowledge of claims payment methodologies, adjudication processes, and state Encounter regulations to uphold compliant reconciliation processes and SLAs.

• Perform additional duties as assigned.

⛳️ Requirements

• A Bachelor’s degree in Science/Arts or equivalent relevant experience is mandatory.

• A Master’s Degree in Science/Arts is preferred, with a focus on Healthcare Analytics or Data Science being advantageous.

• At least one (1) to two (2) years of experience in managed healthcare, claims, or a regulated managed care environment is required.

• A minimum of one (1) year of experience with at least two of the following tools is essential: SQL, SAS, SSIS, MySQL, ORACLE, R, or PowerBI.

• Proficient computer skills are necessary.

• Advanced Excel skills are required.

• Strong data analysis and trending capabilities.

• Proven understanding of claims operations, particularly in relation to encounters.

• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10, and HCPCS coding.

• Familiarity with Claims IT processes/systems and analytical methodologies.

• Experience in documenting business requirements is essential.

• Advanced knowledge of managed care and health claims processing and reimbursement methodologies.

• Exceptional written and verbal communication skills are required.

• Ability to work both independently and collaboratively within a team setting.

• Strong time management skills; capable of multitasking and prioritizing tasks effectively.

• Meticulous attention to detail.

• Strong decision-making and problem-solving abilities.

• Critical thinking and active listening skills are important.

• Licensure and certification: None required.

🏝️ Benefits

• A bonus linked to both company and individual performance may be available.

• A substantial and comprehensive total rewards package.

• An Equal Opportunity Employer environment that promotes belonging and supports individuals from all backgrounds.