Sr. Encounter Analyst

Job Description

What You ll Be Doing :

Medicaid Encounter Operations, Health Plan Services (HPS) is responsible for managing day to day operations for a state Medicaid encounters on behalf of Evolent clients. Operational areas of responsibility include encounter data management, submissions, reject remediation, and client/internal reporting as well as coordination/reconciliation with state regulatory bodies.

This individual must be experienced in managing day to day encounter operations around state Medicaid encounter submissions. This position will report to the Manager , Encounter Operations and is located in the Pune , area.

Mandatory

• Experience working in Client facing engagements and act as key Stakeholder in the TPA functions related to Encounter Management and Reporting.
• Familiarity with claims operations (intake, load, adjudication & payment) and commercial claims platform TriZetto, Xcelys etc.
• Hands-on experience with healthcare EDI X12 transaction sets 837, 835 and 277
• Experience working among Payer & Provider Community to facilitate implementation of improvements of State/Federal Managed Care Programs or similar Care Coordination programs.
• Ability to manage and track the implementation of tasks, operational improvements, and enhancements in order to meet Client specific goals.
• Experience in Executive level clear and concise project status and data management reporting.
• Experience working in vertically aligned cross functional teams to identify interdependencies to support program implementation and enhancements.
• Experience with mentoring and training other Business Analyst to support ongoing operations.
• Hands on experience on concepts COB, Authorization, Duplicate etc.
• Knowledge on HCFA 1500 and UB 04 images.

Responsibilities -

• Responsible for timely, complete, and accurate encounter data submissions that meet or exceed state and/or federal requirements
• Work with HPS Business Operations and IT Engineering to implement a strategic approach to encounter data management encompassing internal and external data sources, technical infrastructure, process automation, and issue/reject remediation workflow
• Identify, develop and drive initiatives to increase the Encounter Operations function regulatory compliance levels, productivity/efficiency, process consistency, and long-term scalability
• Oversee the on-boarding of new encounter clients to include requirements gathering/documentation and coordination with HPS Implementation, Business Operations, and/or HPS Engineering teams (as required)
• Develop and execute action plans to respond to new encounter regulatory requirements
• Efficiently and effectively manage internal and external escalations
• Data management and analysis reporting utilizing SQL, MicroStrategy and similar reporting tools
• Medic aid Encounter management and processing utilizing Encounter Management platform
• Data movement and transformation utilizing Move-IT and SSIS and SFTP protocols, processes and tools

The Experience You ll Need (Required):

• Understanding and experience with standard claim Electronic Data Interchange file formats and protocols such as 837I, 835, 277, 999 among others
• Bachelor s degree in Healthcare Management, Computer Science or another technology/business field of study
• Experience Monitoring, troubleshooting, and correcting EDI transactions in Encounter Management Platform.
• Excellent analytical and problem-solving skills in Healthcare data operations, specifically with Claims and Encounters data.
• Experience working with TPA and establishing Third Party Vendors EDI contractors Encounter Data submission.
• Experience working with Request Management tools like HP QC, ReqPro , JIRA, or similar industry standard tools.
• Ability to perform typical business analyst duties such as requirements gathering, solution design, testing to meet business needs.
• End to End knowledge of Healthcare Payer data operations.
• Experience working in Government Programs Medicare/Medicare.
• Strong SQL Server Management Studio experience or similar products.
• 5-7 yrs experience in leading Medicare encounter operations, Illinois or Florida Medicare market experience a plus
• Experience in healthcare payer systems required and knowledge of Medicare products and programs preferred

Keyskills :
third party vendorssql server management studiobusiness analysissolution designserver managementreporting toolshealthcare managementmanaged careproblem solvingcare coordinationsql servergovernment programsregulatory complianceelectronic data