PacificSource Health Plans

Encounter/Configuration Analyst

Job Location US-OR-Springfield
Job ID
2018-56B
Type
Regular Full-Time
Hiring Pay Range
$17.50 - $22.00 per hour
# of Openings
1
Status
Non-Exempt

Overview

Position Overview: Review, analyze and adjust hospital and professional claims as necessary for Encounter resolution. Research Encounter Edit, identify trends and resolve root cause, which need a higher level of adjudicator expertise, EDI interpretation and decision making for Government lines of business. Contribute to establishing and/or revising claims research policies and procedures and look for ways to improve processes. Work with external vendors contracted for EDI transmissions. Participate in Encounter work groups, across departments and participate or lead other standing or ad hoc workgroups as needed.

Responsibilities

Essential Responsibilities:

  1. Analyze weekly Encounter pend/rejection reports, drilling down to root cause, system improvement opportunities and/or EDI transaction errors. 
  2. Work cooperatively with internal departments and external vendors to review research for appropriate resolution in conjunction with PacificSource policy and applicable laws governing claims processing.
  3. Work independently under tight timelines while maintaining compliance at the company and government regulatory agency level.
  4. Manage monthly and quarterly reports from the OHA within contracted timelines.
  5. Work miscellaneous OHA requests and/or reports as applicable.
  6. Review and resolve claim and system edits using multiple systems, processes and procedures.
  7. Clearly articulate and provide status updates to the Encounter Operations team and management.
  8. Analyze existing and proposed business requirements.
  9. Work with the FBS and FTS teams as applicable to diagnose and resolve configuration and set up issues. Act as liaison between Encounter Operations team and IT work streams.
  10. Work with the Provider Operations and Service teams specific to claims based issues, provider setup, and Medicaid enrollment.
  11. Understand core business functions at a fundamental level.
  12. Understand OHA regulations and contract requirements specific to Encounter Data and claims processing.

Supporting Responsibilities:

  1. Develop and track project plans for large upcoming projects that affect multiple areas.
  2. Ability to judge severity of problems and the need to escalate to management or employ external services.
  3. Support and participate in continuous improvement initiatives.
  4. Maintain professional, service oriented relationships.
  5. Demonstrate ability to organize and prioritize work.
  6. Provide Claims processing assistance to the Claims Department when available.
  7. Report pertinent information back to the Claims Leadership Team.
  8. Meet department and company performance and attendance expectations.
  9. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  10. Perform other duties as assigned.

Qualifications

Work Experience: Minimum five years claims adjudication experience with strong knowledge of Government requirements or equivalent work experience in a related health field. Coding experience is required. EDI knowledge is preferred. 

 

Education, Certificates, Licenses: High school diploma or equivalent required.

 

Knowledge: Advanced proficiency in Microsoft Office Applications including Word and Excel. Intermediate knowledge of Government Programs (Medicare/Medicaid) structure, medical coding and medical terminology required. Knowledge of claims and provider network strongly encouraged. Intermediate understanding of EDI files and industry standard X12 specifications and requirements. Excellent Time Management, Critical Thinking and Research skills required.

 

Competencies

Our Values

  • Adaptability
  • Building Customer Loyalty
  • Building Strategic Work Relationships
  • Building Trust
  • Continuous Improvement
  • Contributing to Team Success
  • Planning and Organizing
  • Work Standards
  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for our customers’ experience.
  • We practice open communication at all levels of the company to foster individual, team and company growth.
  • We actively participate in efforts to improve our communities-internal and external.
  • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.

 

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

 

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

 

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

 

PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

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