Claims Rules & Encounter Optimization Analyst

Community Behavioral Health; Philadelphia (Philadelphia County); On-site; USD 57,000 - 78,000; Full time

Job summary

Community Behavioral Health seeks a Business Rule Management Analyst to ensure accurate and timely submission of encounter data to the State while maintaining and updating the claims adjudication system to reflect approved business rules.

The role requires coordinating with Claims, IT, and business owners to translate requirements into system functionality, conducting testing, and ensuring compliance with CBH policies and contractual obligations.

Qualifications

• At least 3 years of experience in Claims or Behavioral Health.
• Proficient in Excel and Word.
• Thorough understanding and knowledge of claims submission requirements.
• Detail-oriented and accurate data entry skills.
• Strong organizational skills.

Responsibilities

• Monitor encounter submissions to ensure data is accurate, complete, timely, and compliant with State requirements.
• Review State encounter response files to identify trends and recurring issues; perform root-cause analysis.
• Translate business requirements into system rules and configurations for claims adjudication.
• Test and document changes; ensure transitions meet CBH processes and policies.
• Analyze claims and encounter data to identify trends and opportunities for improvement.

Skills

Analytical thinking

Problem solving

Excel

Word

Tools

HIPAA EDI 5010

X12 837P

837I

835

277CA

TA1

999

Job description

Community Behavioral Health seeks a Business Rule Management Analyst to ensure accurate and timely submission of encounter data to the State while maintaining and updating the claims adjudication system to reflect approved business rules.

The role requires coordinating with Claims, IT, and business owners to translate requirements into system functionality, conducting testing, and ensuring compliance with CBH policies and contractual obligations.