Senior Analyst, Encounters (Medicare)

Molina Healthcare; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Molina Healthcare is seeking a Sr Analyst, Encounters to monitor and improve encounter submissions across markets. You will analyze data, identify root causes, and collaborate with IT, health plan, claims, and provider teams to remediate issues.

The role involves maintaining submission criteria, KPIs, and preparing materials for governance reviews, with a focus on timely and accurate processing and regulatory compliance.

Qualifications

• 3+ years of experience in billing, claims, encounters, and/or data analysis
• Experience with data analysis techniques
• Skilled with writing basic to advanced queries (SQL)
• Strong organizational and time management skills
• Ability to work cross-collaboratively across teams/functions
• Strong verbal and written communication skills
• Proficiency with Microsoft Office and applicable software programs

Responsibilities

• Monitors inbound and outbound encounters submissions and responses, interprets outcomes, and takes swift action to remediate errors
• Routinely reviews submission results and analyzes encounter pend and rejection inventory, coordinating with IT, health plan, claims, provider, enrollment, regulators, and vendors
• Owns and maintains encounter submission criteria, submission schedule, and market-specific documentation
• Maintains market/state KPIs and reports monthly and quarterly results
• Understands and communicates financial and performance impacts related to encounter submissions
• Assists with materials for Monthly Governance and Operations Reviews
• Performs root cause analysis of claims and encounter data and designs system changes
• Writes business requirements for system updates to resolve errors
• Participates in/returns leadership on projects addressing corrections and updates for encounter submissions
• Develops basic reports for error resolution, follow-up, and performance monitoring
• Understands data compliance for encounters submission
• Monitors vendor encounter submissions, contractual compliance, and SLAs

Skills

Data analysis

SQL queries

Organizational skills

Cross-functional collaboration

Communication (verbal/written)

Microsoft Office

Tools

SQL

Microsoft Office

Job description

JOB DESCRIPTION

Job Summary

The Sr Analyst, Encounters is responsible for monitoring inbound and outbound encounter processes and ensuring timely, accurate, and complete encounter submissions for moderate- to high-complexity markets or states. Performs data analysis using internal and external sources, analyzes processes and provides recommendations for improvement to decision-makers. At the direction of the Manager, Encounters, collaborates with cross-functional teams to identify and resolve root causes of issues that impact encounters and identify improvements to operational performance.

Job Duties

• Monitors inbound and outbound encounters submissions and responses, interprets outcomes, and takes swift action to remediate errors
• Routinely reviews submission results and analyzes encounter pend and rejection inventory, and works with other areas including IT, health plan, claims, provider, enrollment, regulators, and external vendors, as needed, to remediate encounter errors and ensure timely, accurate, and complete encounter submissions
• Owns and maintains encounter submission criteria, maintains submission schedule, central documentation of market nuances, compliance, and regulatory requirements for primary market or state
• Responsible for maintaining market or state-specific KPIs, and reports monthly and quarterly results
• Understands and communicates financial and performance impacts related to encounter submissions
• Assists with preparing portions of materials and information for Monthly Governance and Operations Reviews
• Performs root cause analysis of claims and encounter data and develops recommendations based on data and industry knowledge. Collaborates across departments to design and implement systems changes to meet encounter data processing and submission goals.
• Writes business requirements for system updates to resolve errors and optimize encounter performance
• Participates in and/or leads projects to address corrections, changes, and updates to ensure encounter submissions acceptance.
• Develops basic reports and distributes to appropriate departments for error resolution, follow up, and performance monitoring.
• Understands provider, member, and, inbound claims data compliance in relation to encounters submission requirements
• Monitors vendor encounter submissions, contractual compliance, and SLAs

Required Qualifications

• At least 3 years of experience in billing, claims, encounters, and/or data analysis, preferably in an analyst capacity in a managed care setting, or equivalent combination of relevant education and experience.
• Experience with data analysis techniques.
• Skilled with writing basic to advanced queries.
• Strong organizational and time management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Ability to work cross-collaboratively across teams/functions.
• Strong verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

PREFERRED EXPERIENCE

• Claims processing, provider contacting, health data analysis and reporting, project management, working with various levels of management throughout multiple organizations
• Managed care experience
• 5-7 years of experience in billing, claims, encounters, and data analysis
• 5 years or more of managed care experience
• Knowledge of advanced data analysis techniques
• Skilled with writing basic to advanced SQL queries

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION

Certified Professional Coder (CPC)

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V