This position is responsible for data analysis and research of claim and encounter data to optimize risk adjustment acceptance rates for clients with Medicare, Medicaid and Exchange lines of business.
RESPONSIBILITIES:
Responsible for documenting, monitoring and analyzing the end-to-end encounter life cycle, inbound and outbound encounter process.
Identifies and interprets encounter data, submission requirements and performance metrics per the regulatory and health plan guidelines.
Researches and documents all encounter errors in established systems(s)/database(s) with appropriate statistical and trend analysis
Performs root cause analysis of claims/encounters processing and submission issues; develops recommendations based on data and industry standards.
Collaborates across various departments to design and implement any business process and/or systems changes to meet encounter data processing and submission goals.
Communicates with and provides clear, detailed, effective documentation to other departments within the organization on issues causing encounter pends/denials and potential solutions.
Collaborates with the Health Plans or Product teams on any encounter related issues
Communicates regularly with supervisors on issues discovered through research efforts
Develops various encounter related reports (Weekly/Monthly outstanding encounter logs)
Ensures updating the Issue trackers on a daily basis and timely sharing of agenda prior to client calls
Owns and maintains the desktop procedures, workflows and policy and procedure documents for encounters
Works to optimize business performance by recommending balanced approaches to system design and operational/process oriented solutions
Review and research inquiries from regulatory bodies and/or the Health Plans related to submission data including the score cards from the Health Plans
Proactively monitors the performance of encounters metrics and recommend system/business process adjustments as applicable
Other duties as assigned
REQUIREMENTS:
Bachelor’s Degree or above
3-5 years working in the health payer industry with proficient level understanding of general business practices and health plan operations (Membership, Provider, Claims, Customer Service, Care Management, etc.) required.
Experience working with ANSI x12 EDI standards for health care required. Solid analytical skills with ability to compile data from many sources and formulate plans and recommendations.
Excellent data manipulation, communication, analytical and statistical skills are required. Must be comfortable with SQL, MS Excel.
Must have excellent time management and organizational skills with the ability to handle multiple tasks in a timely and accurate manner.
Ability to work under pressure, adhere to deadlines and know when to escalate information/issues.
Must have a high level of self-motivation and with little guidance/supervision.
Must be able to work both independently as well as a team participant.
Must have outstanding verbal and written communications skills with the ability to communicate clearly to all levels of an organization.
Must have strong interpersonal skills. Three (3) plus years health plan operations analysis or related work preferred.
Experience with multiple health plan operation functional areas. Knowledge of Medicare, Medicaid, TPA business requirements is a plus.