Job description
Job Summary:
The Encounters Systems Analyst II is responsible for performing analysis of Encounters data and understanding the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements are achieved.
Essential Functions:
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
Education and Experience:
Bachelor’s degree in Science/Arts or equivalent years of relevant work is required
Master’s Degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred
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
Competencies, Knowledge and Skills:
Intermediate computer skills, Advanced skills in Excel
Edifecs knowledge is preferred
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
Knowledge of Agile is preferred
Knowledge of Facets is preferred
Experience in Documentation of business requirements
Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
Experience with 837O files to States and/or CMS (MA EDS) preferred
Experience with 835 files preferred
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
Licensure and Certification:
None
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
SalaryOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSourceOriginally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.