Encounters Systems Analyst II

CareSource; Kentucky; Hybrid; USD 63,000 - 100,000; Full time

Job summary

CareSource is seeking an Encounters Systems Analyst II to analyze Encounter data and assess the financial and clinical impact of changes on business processes to meet SLAs.

The role involves supporting regulatory data projects, reviewing Encounter rejections, and collaborating with CMS/state agencies. Strong data skills, healthcare domain knowledge, and Excel proficiency are essential.

Qualifications

• Bachelor’s degree in Science/Arts or equivalent years of relevant work is required.
• Master’s Degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred.
• Minimum of one (1) year to two (2) years of managed healthcare, claims, or managed care regulated environment experience is required.
• Minimum of one (1) year of experience using at least two of the following tools is required: SQL, SAS, SSIS, MySQL, ORACLE, R, or PowerBI.

Responsibilities

• Analyze Encounter data.
• Understand the financial and clinical impact of changes to ensure SLAs are achieved.
• Support regulatory data projects.
• Review Encounter rejections and resolve data issues.
• Support CMS and State agencies SME for Encounters.
• Build and sustain relationships to improve Encounter Data processes.
• Assist in testing and delivering processes to the business.
• Participate in claims data processes to ensure accuracy and compliance with CMS/state agencies.
• Participate in key data management and readiness to state and governing entities.
• Assist in regulatory reporting and analytics; make recommendations for enhancements.

Skills

Excel

Data analysis

Communication

Time management

Attention to detail

Critical thinking

Problem solving

Team collaboration

Multi-tasking

Analytical mindset

Education

Bachelor’s degree in Science/Arts

Master’s Degree in Science/Arts

Tools

SQL

SAS

SSIS

PowerBI

Oracle

MySQL

R

Job description

Job Summary

Encounters Systems Analyst II is responsible for performing analysis of Encounters data and understanding the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements are achieved.

Essential Functions

• Perform analysis of Encounter data.
• Understand the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements (SLAs) are achieved.
• Support for Regulatory Data projects.
• Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes.
• Support for Claims Encounter Subject Matter Expertise (SME) for both CMS and State agencies and internal CareSource impacted organizations (IT, Claims, New Business, Enrollment, etc.).
• Build, sustain and leverage relationships with persons within his/her area of responsibility to allow for continuous improvement of the Encounter Data business process.
• Support for testing and delivering process to business.
• Participate in claims data processes to ensure accuracy and compliance with CMS and state agencies.
• Participate in the key claims data management and readiness to state and governing entities.
• Understand the Claims Encounter Data requirements in detail to enable one to support efforts to ensure claims data submissions achieve the required SLAs through requested changes internally and externally.
• Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies.
• Support Claims Encounters regulatory reporting.
• Support for critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements.
• Monitor various management and oversight metrics and reports as required.
• Support Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with reporting department.
• Provide support of vendors, managing SLA’s, regulatory requirements and contractual metrics.
• Maintain positive and strategic relationships with internal and external stakeholders.
• Contribute to and/or develop user stories or provide user story guidance for sprint planning.
• Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLA’s.
• Perform any other job duties as requested.

Education and Experience

• Bachelor’s degree in Science/Arts or equivalent years of relevant work is required.
• Master’s Degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred.
• Minimum of one (1) year to two (2) years of managed healthcare, claims, or managed care regulated environment experience is required.
• Minimum of one (1) year of experience using at least two of the following tools is required: SQL, SAS, SSIS. MySQL, ORACLE, R, or PowerBI.

Competencies, Knowledge and Skills

• Intermediate computer skills.
• Advanced skills in Excel.
• Edifecs knowledge is preferred.
• Data analysis and trending skills.
• Demonstrated understanding of claims operations specifically related to encounters.
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding.
• Knowledge of Claims IT processes/systems and analytic processes.
• Knowledge of Agile is preferred.
• Knowledge of Facets is preferred.
• Experience in Documentation of business requirements.
• Advanced working knowledge of managed care and health claims processing and reimbursement methodologies.
• Experience with 837O files to States and/or CMS (MA EDS) preferred.
• Experience with 835 files preferred.
• Excellent communication skills; both written and verbal required.
• Ability to work independently and within a team environment.
• Time management skills; capable of multi-tasking and prioritizing work.
• Attention to detail.
• Effective decision making / problem solving skills.
• Critical thinking and listening skills.

Licensure and Certification

• None

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time.

Compensation Range

• $62,700.00 - $100,400.00

Compensation Type

• Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

Equal Opportunity & Belonging

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Job Description Waiver

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.

CareSource Mission

Brand=CareSource The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.