This position is responsible for data analysis and electronic submission of encounter data to the appropriate government entity for Medicare, Medicaid and Exchange markets.
RESPONSIBILITIES:
Work with Project Manager and Systems Integration Team during implementations and upgrades to gather business requirements, create test case scenarios, analyze test results, and validate releases
Configuration and maintenance of the Encounter Data Manager (EDM) application
Follow the encounter submission process to extract claim data from the source database and use the EDM application to create 837 files to submit to government entities
Processes data and develop reports for analysis and assigned projects, including the use of SQL, Excel (pivot tables, look-ups, advanced formulas, regressions, etc.), and other tools
Review and analyze information using various statistical methods such as regression analysis and other graphical techniques such as scatter plots, bar charts, trend lines, etc.
Analyze encounter data to find root cause for encounters still outstanding due to scrubbing prior to file generation, or rejection by the government entity
Develop, maintain and standardize processes through the use of scripts, stored procedures and packages in order to provide quality assurance reviews.
Query tables in the claim source and EDM database to determine encounter status and perform reconciliation
Track results of response files to monitor Service Level Agreements for the client and compliance measurements
Identify trends in data or process issues that need to be researched and resolved
Own, update and maintain version control of EDM Mapping Documents of 837 files for all databases such as Facets and QNXT or for custom databases for TPV file layouts
Collaborate and work closely with other business units to promote effective working relationships and support efforts to maintain data integrity
Follow the RAPS submission process to extract claim data from the source database and use the CDM application to create RAPS files to submit to government entities
Query tables and CDM application to determine claim/cluster status and perform analysis to confirm successful submissions of data to government entities
REQUIREMENTS:
Requires Bachelor's degree in Information Technology, Information Systems, Business or other related field, or
10 years related healthcare and/or IT experience with specific knowledge including claims, membership, provider maintenance, code sets, EDI including 837 and NCPDP file formats, and CMS compliance
Risk Adjustment experience is a plus
Strong background and knowledge of SQL (Structured Query Language) and SSRS (SQL Server Reporting Services)
Facets, EDM, and CDM (Claims Data Manager) experience a plus
Experience with User Acceptance Testing (UAT)
Excellent work ethic and the ability to work both independently and as part of the team with a willingness to do whate it takes to get the job done
Strong analytical and problem solving skills with the ability to troubleshoot problems quickly and efficiently
Must be able to pay attention to detail and have strong organizational abilities
Flexibility, high aptitude for multitasking, and the ability to manage deadlines
Able to identify and follow specific processing steps but also have the ability to determine next steps when issues arise
Ability to identify and learn from mistakes or issues
Proficient in Microsoft Office and the ability to create and maintain logs and complex spreadsheets in MS Excel and develop detailed desk level procedures (DLPs) in MS Word
Strong written and clear verbal communication skills with the ability to do internal and customer-facing presentations
The ability to understand and keep current on reported issues to provide status updates and be able to answer related questions during client meetings
Self-starter, takes pride in a job well done, willing to take initiative and ownership, and can follow through to the end