Note: The job is a remote job and is open to candidates in USA. 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
Benefits
- You may qualify for a bonus tied to company and individual performance.
- Remote work
Company Overview
Company H1B Sponsorship