Senior Encounter Operations Analytics Lead

Gold Coast Health Plan; California (MO); On-site; USD 91,667 - 128,333; Full time

Job summary

Gold Coast Health Plan is seeking an experienced Encounter Operations professional to serve as a technical subject matter expert. The role focuses on researching, analyzing, and resolving complex encounter, claims, and reimbursement issues while ensuring data quality and regulatory compliance.

The position requires collaboration with multiple stakeholders, oversight of encounter submissions, and participation in process improvements. California residency is required for this role.

Qualifications

• Requires knowledge of Medi-Cal, Medicare, and D-SNP programs and related regulatory requirements.
• Experience with healthcare claims processing and billing/coding methodologies (CPT, HCPCS, ICD-10-CM/PCS).
• Understanding encounter reporting requirements, life cycle, adjudication, and regulatory submission concepts.
• Proficiency in data analysis, reporting, and using MS Office applications.

Responsibilities

• Serve as technical SME for Encounter Operations, researching and resolving complex issues.
• Monitor encounter production, submission status, data quality, and regulatory compliance.
• Perform advanced encounter validation and reconciliation with source data for accuracy.
• Lead root cause analysis of encounter processing issues and remediation actions.
• Support business requirements, UAT, production deployment, and post-production monitoring.

Skills

Encounter operations

Data analysis

Root cause analysis

Stakeholder collaboration

Education

High School Diploma or GED

Tools

Microsoft Office

Excel

Job description

Gold Coast Health Plan is seeking an experienced Encounter Operations professional to serve as a technical subject matter expert. The role focuses on researching, analyzing, and resolving complex encounter, claims, and reimbursement issues while ensuring data quality and regulatory compliance.

The position requires collaboration with multiple stakeholders, oversight of encounter submissions, and participation in process improvements. California residency is required for this role.