Business Encounter Data Analyst

WellSense Health Plan is a growing regional health insurance company with a 25-year history of providing health insurance that works for our members. The Business Encounter Data Analyst is responsible for compiling and analyzing encounter data to ensure compliance with CMS and State Service Level Agreements, while working closely with business and technical resources to document and improve business processes.

Responsibilities:

• Understand the claims encounter data requirements in detail to ensure claims data is complete, accurate, and timely
• Responsible for reviewing encounter rejections and providing resolution of minor to complex data/system issues or processes
• Responsible for the development and maintenance of supporting business processes and workflows
• Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies
• Provide critical analysis of functional performance, and make recommendations for enhancements, and process improvements
• Build, sustain and leverage relationships to constantly allow for continuous improvement of the encounter data business process
• Provide encounter data support to vendors and ensure understanding of regulatory encounter requirements
• Participate in claims encounter initiatives such as working with IT and others internal departments to automate claims encounters functions
• Understanding of how claims payment methodologies, adjudication processing and CMS and State encounter regulations interrelate to maintain compliant encounter reconciliation processes and SLA’s
• Stay current with the needs and operations of the regulatory deliverables
• Interacts with business stakeholders, internal and external as appropriate, to understand new business requirements and enhancement requests
• Provide business encounter subject matter expertise for internal departments and both CMS and State agencies
• Performance for timely and accurate reviews must meet or exceed internal, CMS, and State SLA requirements
• Other duties as assigned

Requirements:

• Bachelor's Degree in a related field or the equivalent combination of training and experience
• 5 or more years experience in a fast paced, managed healthcare environment
• 5 or more years experience with encounter data operations, claims processing, and/or provider billing
• 3 or more years of claim coding and billing processes, including CPT, ICD-10 and HCPCS coding
• Advanced knowledge of HIPAA regulations and 837 EDI standards
• Experience working with Medicaid, Medicare or commercial encounter, coding and/or regulatory guidelines
• Successful completion of pre-employment background check
• Effective collaborative and proven process improvement skills
• Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation
• A strong working knowledge of Microsoft Office products
• Independent thinker and problem solver with an analytical mind and the ability to solve complex data and workflow issues
• Detail oriented
• AHIMA or other nationally recognized Coding/Billing Certification
• Edifecs encounter data software
• Cognizant Facets claim adjudication system
• Experience with industry standard payment rules and methods