Encounters Specialist

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You Will Focus On

• Stay updated with CMS guidelines and Health plan data submission guidelines.
• Ensure operational encounter data submissions are meeting industry and individual health plan requirements.
• Outreach for health plans regarding encounter data submissions, serving as a resource and liaison.
• Analyzes and interprets encounter data to identify potential issues and trends.
• Coordinate and perform the correction of data rejections so that files may be resubmitted, error free.
• Monitor daily administrative duties of Encounter Data. This includes direct response to external and internal customers’ issues which may arise, ensuring resolution to customer satisfaction.
• Conduct monthly reconciliation audit of encounter data submissions.
• Maintain clear documentation of encounter data workflow by health plan and submission method.
• Responsible for oversight of encounter data enhancements to include identification, recommendation, coordinating request and implementation of enhancement(s) to ensuring compliance.
• Supports department projects/tasks as they arise. This includes generating standard and ad-hoc reports, managing contact list, and monitoring metrics.
• Facilitates regularly scheduled Encounter Data Workgroup meetings.

The Skills, Experience & Education You Bring

• BA/BS degree in Business, Information Systems, or other related field preferred or equivalent experience and training
• Three (3) to Five (5) years’ experience in operations, data analysis or information
• management in the insurance and/or delivery system in the healthcare industry
• Three (3) to Five (5) years’ knowledge of healthcare administrative functions, including claims processing, remittance advice processing, eligibility, verifications, etc.
• Three (3) to Five (5) years’ experience of Government billing regulations experience,
• including Medicare, Medicare Managed Care, and Medical Terminology
• Three (3) to Five (5) years’ experience on EDI format and Claim/Encounter workflows (837,277,835)
• Two (2) to Four (4) years’ experience working with different payer and clearinghouse partners.
• Two (2) or more years’ analytical experience in a support role
• Two (2) to Four (4) years’ experience of CMS Risk Adjustment & HCC Methodology preferred.
• Two (2) to Four (4) years’ experience in current and progressive healthcare experience in both provider and payer domains
• Two (2) to Four (4) years’ Epic AP Claims hands-on experience
• EDI, HIPAA, and Healthcare expertise with business and technical expertise
• Outbound EDI 837 (professional and institutional) familiarity desired.
• Demonstrated excellent analytical, problem-solving and writing skills
• Intermediate Excel, Access, Word, and PowerPoint skills.