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Tech Stack
Tools & technologiesMySQLOracleSQLSSIS
About the role
Key responsibilities & impact- Perform analysis of Encounter data
- Understand the financial and clinical impact of changes and decisions to business processes to ensure Service Level Agreements are achieved
- Support Regulatory Data projects
- Review Encounter rejections and provide resolution of minor to complex data issues or process changes
- Provide Claims Encounter subject matter expertise for CMS, state agencies, and internal CareSource organizations
- Build and leverage relationships to support continuous improvement of Encounter Data business processes
- Support testing and delivery of processes to the business
- Participate in claims data processes to ensure accuracy and compliance with CMS and state agencies
- Participate in claims data management and readiness for state and governing entities
- Support claims data submissions and required SLAs through internal and external changes
- Identify inconsistencies and gaps to improve productivity, accuracy, data usability, procedures, and policies
- Support Claims Encounters regulatory reporting
- Support performance reporting and analysis, recommending enhancements, cost savings initiatives, and process improvements
- Monitor management and oversight metrics and reports
- Support Claims Encounter initiatives, including automation with IT and improvements to regulatory report development
- Support vendors and manage SLAs, regulatory requirements, and contractual metrics
- Maintain strategic relationships with internal and external stakeholders
- Contribute to or develop user stories and provide user story guidance for sprint planning
- Apply knowledge of claims payment methodologies, adjudication processing, and state Encounter regulations to maintain compliant reconciliation processes and SLAs
- Perform other duties as requested
Requirements
What you’ll need- 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
- 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 written and verbal communication skills 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 and problem-solving skills
- Critical thinking and listening skills
- Licensure and certification: None
Benefits
Comp & perks- Bonus tied to company and individual performance may be available
- Substantial and comprehensive total rewards package
- Equal Opportunity Employer environment fostering belonging and supporting individuals of all backgrounds