The Encounter Data Analyst evaluates encounter data and identifies errors created by operational claims and eligibility processes. This position will research, analyze, summarize and categorize all types of encounters based on response files from the Oregon Health Authority (OHA), as appropriate. This position also works closely with other internal departments, delegated entities, vendors and government agencies to monitor and communicate that encounter data is submitted and processed appropriately.
The Encounter Data Analyst will need to understand the overall data, process flows and provider data used with the OHA and work with internal teams and delegated entities to create targeted and ongoing reports to track and monitor data accuracy and timeliness. This position will also support PacificSource teams in working collaboratively with partners to improve overall encounter, member and provider data quality.
1. Review, analyze and adjust hospital and professional claims as necessary for Encounter pend resolution.
2. Collaborate with other departments, vendors and delegates to identify missing data, errors or other anomalies; works with them to correct these encounter data errors, gather necessary information and provide guidance on regulatory reporting needs.
3. Work with minimal supervision under tight timelines while maintaining compliance at the company and government regulatory agency level.
4. Work and respond to miscellaneous OHA requests and/or reports as applicable.
5. Ability to access and analyze data from Transaction Manager, MMIS, CIM, CVS and Facets.
6. Clearly articulate and provide status updates to the Encounter Operations team and management.
7. Understand and abide by existing business requirements.
8. Work with the Provider Operations and Service teams specific to claims based issues, provider setup and Medicaid enrollment.
9. Understand core business functions at a fundamental level.
10. Understand OHA regulations and contract requirements specific to Encounter Data and claims processing.
11. Participate in Encounter work groups, across departments and participate or lead other standing or ad hoc workgroups as needed.
1. Ability to judge severity of problems and the need to escalate to peers and/or management.
2. Support and participate in continuous improvement initiatives.
3. Maintain professional, service oriented relationships.
4. Provide Claims processing assistance to the Claims Department when available.
5. Report pertinent information back to the leadership as applicable.
6. Perform special projects and other duties as needed.
Work Experience:Minimum three years claims adjudication experience or related healthcare experience required. EDI experience is preferred. Demonstrated ability to conduct detailed research of claims, systems reports, etc.
Education, Certificates, Licenses:High school diploma or equivalent required. Coding certification preferred.
Knowledge:Proficiency in Microsoft Office Applications. Working knowledge of the Government Programs (Medicare/Medicaid) structure, medical coding and medical terminology required. Familiarity of claims and provider network strongly encouraged. Understanding of EDI and industry standard X12 specifications and requirements. Demonstrated organizational and time management skills.
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 indentity or age.