Senior Analyst, Encounters (Medicare)

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 : Hands on experience with Edifecs, including use of the Edifecs application/interface for encounter processing, monitoring, troubleshooting, testing, and issue resolution. Experience supporting Edifecs implementations or system migrations is highly preferred. Strong knowledge of EDI and healthcare transaction standards, including X12 transactions such as 837, and 999/277CA, with experience analyzing EDI files and responses to identify data, mapping, and processing issues. 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 Claims processing, provider contacting, health data analysis and reporting, project management, working with various levels of management throughout multiple organizations Managed care experience PREFERRED LICENSE, CERTIFICATION, ASSOCIATION : Certified Professional Coder (CPC) To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V