Encounters Systems Analyst II

Summary

CareSource is a managed healthcare organization. The Encounters Systems Analyst II analyzes encounter and claims data, evaluates financial and clinical impacts, and supports regulatory compliance and service-level achievement. The role also resolves data issues, supports reporting and testing, collaborates with internal and external stakeholders, and contributes to process improvements and automation initiatives.

Responsibilities

• Perform analysis of 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
• Support for Regulatory Data projects
• Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes
• Support for 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 area of responsibility to allow for continuous improvement of the Encounter Data business process
• Support for testing and delivering process to business
• Participate in claims data processes to ensure accuracy and compliance with CMS and state agencies
• Participate in the key claims data management and readiness to state and governing entities
• Understand the Claims Encounter Data requirements in detail to enable one to support 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
• Support Claims Encounters regulatory reporting
• Support for critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
• Monitor various management and oversight metrics and reports as required
• Support Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with reporting department
• 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

Skills

• Bachelor's degree in Science/Arts or equivalent years of relevant work is required
• Minimum of one (1) year to two (2) years of managed healthcare, claims, or managed care regulated environment experience is required
• Minimum of one (1) year of experience using at least two of the following tools is required: SQL, SAS, SSIS. MySQL, ORACLE, R, or PowerBI
• Intermediate computer skills, Advanced skills in Excel
• Data analysis and trending skills
• Demonstrated understanding of claims operations specifically related to encounters
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
• Knowledge of Claims IT processes/systems and analytic processes
• Experience in Documentation of business requirements
• Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
• Excellent communication skills; both written and verbal required
• Ability to work independently and within a team environment
• Time management skills; capable of multi-tasking and prioritizing work
• Attention to detail
• Effective decision making / problem solving skills
• Critical thinking and listening skills
• General office environment; may be required to sit or stand for extended periods of time
• Master's Degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred
• Edifecs knowledge is preferred
• Knowledge of Agile is preferred
• Knowledge of Facets is preferred
• Experience with 837O files to States and/or CMS (MA EDS) preferred
• Experience with 835 files preferred

Qualifications

Must Haves

• Bachelor's degree in Science/Arts or equivalent years of relevant work is required
• Minimum of one (1) year to two (2) years of managed healthcare, claims, or managed care regulated environment experience is required
• Minimum of one (1) year of experience using at least two of the following tools is required: SQL, SAS, SSIS. MySQL, ORACLE, R, or PowerBI
• Intermediate computer skills, Advanced skills in Excel
• Data analysis and trending skills
• Demonstrated understanding of claims operations specifically related to encounters
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
• Knowledge of Claims IT processes/systems and analytic processes
• Experience in Documentation of business requirements
• Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
• Excellent communication skills; both written and verbal required
• Ability to work independently and within a team environment
• Time management skills; capable of multi-tasking and prioritizing work
• Attention to detail
• Effective decision making / problem solving skills
• Critical thinking and listening skills
• General office environment; may be required to sit or stand for extended periods of time

Nice to Haves

• Master's Degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred
• Edifecs knowledge is preferred
• Knowledge of Agile is preferred
• Knowledge of Facets is preferred
• Experience with 837O files to States and/or CMS (MA EDS) preferred
• Experience with 835 files preferred

Benefits

• You may qualify for a bonus tied to company and individual performance.
• Remote work