Claims Encounter Data Analyst

Salary Range: $78,454.00 - $113,758.00

The Encounter Data Quality Analyst is responsible for providing analytical and reporting support to the Claims Operations, Outsourced Vendors and IT support team related to the processing and delivery of encounter data. Validates and analyzes reports and logs related to the processing of 837 transactions to ensure compliance, accuracy, completion and timeliness, as well as ongoing process improvement. Position reports to the Associate Director of Claims.

Duties and Responsibilities

• Adhere to regulatory and internal guidelines in conjunction with CenCal Health policies and procedures as they apply to both internal and external encounter reporting
• Perform data analysis of submitted encounter data files from external entities and produce regular reports of findings
• Work in conjunction with outside vendors on claim file submission rejections to assure corrections are made so that clean data is being submitted prior to each load into the Caradigm system
• Monitor and analyze encounter data reporting of encounter data
• Maintain a thorough knowledge of CenCal Healths encounter data reporting requirements
• Analyze, interpret, and summarize encounter data for development of solutions for reducing and mitigating errors
• Analyze existing and future encounter submission regulatory guidelines to ensure compliance with system editing logic
• Work in conjunction with the IT department on encounter data issues and process development related to successful encounter management
• Work in conjunction with outside vendors on encounter data issues and develop a process to assure quality data is being provided
• Work cooperatively on ongoing Encounter Data Process Improvement projects with other CenCal Health departments as well as external vendors and Provider Community
• Maintain spreadsheets for reporting of encounter related projects both within the department as well as company wide
• Recommend corrective action to resolve processing and data issues
• Perform other duties as assigned

Skills/Knowledge/Abilities

• Experience with EDI 837 transactions for claims and encounters
• Technical knowledge related to claims/encounter data including understanding of coding systems (e.g. CPT/HCPCS, ICD-9/10, NDC)
• Ability to diagnose problems with EDI processes by working effectively with internal departments and third parties
• Assist in the formulation of policies and procedures related to the encounter data process; understand and interpret policies, procedures and regulations
• Proficient use of MS Access, Excel and Word and/or SQL
• Knowledge of data analysis methods used in the encounter/claim submission process
• Knowledge of Medi-Cal program guidelines, regulations and data reporting requirements
• Analytical and problem solving skills
• Excellent verbal and written communication skills
• Team player who builds effective working relationships
• Ability to work independently
• Ability to attend meetings and participate in small teams effectively
• Detail oriented

Education and Experience

• Bachelors Degree in Health Care Administration, Business Administration or related fields preferred
• Two Three (2-3) years in data analysis in a managed health care environment; claims experience is highly desirable
• Any combination of education, training and experience that would provide the knowledge and abilities listed
• Experience in healthcare system configuration
• Experience in analysis
• Must be proficient in the MS Suite of software and have intermediate-advances skills in Excel
• Familiarity with database systems
• Must be experience in Oracle database systems