CLAIMS AND ENCOUNTER ANALYST II

JOB PURPOSE:

The Claims and Encounter Analyst II enhances the efficiency and effectiveness of the claims department by analyzing data, refining processes, and ensuring compliance with State, CMS, and contractual guidelines. This role requires knowledge of Government Programs medical claims and authorization data analytics, encounter process, risk adjustment, and a strong focus on data-driven process improvement.

JOB RESPONSIBILITIES:

Medical Economics/ Claims Analysis:

• Conduct in-depth claims analysis, root cause investigations, and identify process improvement opportunities.
• Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.
• Work with vendors to identify sources of opportunities to improve claims process for providers.
• Evaluate and revise SLAs with the claims TPA to improve operational efficiency; track and monitor open tickets and configuration updates.
• Leverage multiple data sources to develop scheduled and ad-hoc reports to enable process and trend analysis.

Encounter and Risk Adjustment Analysis:

• Assist the Director with analytics to support Medicare risk adjustment process through advanced medical records review to identify and code all relevant diagnoses, including chronic conditions utilizing ICD-10 coding guidelines.
• Assists improve the risk adjustment surveillance process.
• Validate DRG grouping and pricing outcomes; possess basic knowledge of HCC and ICD-10.
• Analyze claims data to identify risk-adjustable conditions and uncover opportunities to improve risk capture processes through data-driven insights and recommendations.
• Review, validate, and reconcile claim and encounter data submissions for completeness, timeliness, and compliance.
• Analyze trends in encounter rejections and denials; develop improvement plans.
• Maintain the integrity of encounter data submission workflows and documentation to support audits.

Statutory and Regulatory Reporting, including support to Quality and Clinical Services departments:

• Work with department heads and business owners, collect and prepare data for state, federal, and internal inquiries (e.g., HPMS, IPRO), ensuring accuracy and regulatory compliance.
• Analyze and understand data from various source systems to validate data quality and ensure that business reporting needs are fulfilled through a formal, documented process.
• Prepare quarterly utilization metrics to support the timely and accurate submission of miscellaneous state reporting, i.e. PACEOR, VBPTR, MLR.
• Assist department heads and business owners in identifying and performing appropriate analyses to enable sound decision-making.
• Work with business users, report writers, Data Warehouse team, and enterprise data architect to refine/adapt/maintain ETL mappings as business users needs change or the data environment changes.

Provider Scorecard Reporting:

• Develop monthly provider scorecards to assess network provider performance and identify improvement areas.
• Perform in-depth analytics on provider performance against the Quality Incentive Program to ensure adherence and accurate incentive payments based on contracts.
• Coordinate with Finance on check runs, provider payments, and resolution of over/underpayments.
• Develop and deliver business intelligence solutions and associated reporting using various Enterprise Data Warehouse (EDW) applications and BI tools (specifically using SQL Server, Tableau Server, Power BI, etc.); revise reporting dashboards as needed.
• Other duties as assigned.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: Bachelor's degree is required; quantitative discipline is strongly preferred. Master’s degree is preferred.

Experience:

• Three to five (3-5) years of managed care (Medicaid and Medicare) data analytics is required.
• Proficiency in data analytics, i.e. SAS, SQL, one or the other is required.
• Claims adjudication and understanding of claims PPS is strongly preferred.
• Knowledge of Medicaid and Medicare benefits, enrollment and billing, and provider contracting is strongly preferred.
• Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS is preferred.
• Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software is required.
• Effective oral, written, and interpersonal communication skills are required.
• Able to multitask efficiently, effectively, and timely.
• Strong organizational skills and work ethic.
• Detail-oriented, professional and collaborative, a great team player.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
• Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
• Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (Language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.