Position is responsible for monitoring and managing monthly encounter data submissions ensuring timely and accurate submissions. Position is responsible for monthly auditing and reconciliation of encounter submission counts from IT to Clearinghouses and/or direct submission partners. Position is responsible for coordinating and performing corrections to encounter data rejects; coordinating efforts with internal departments and external customers (health plans and clearinghouses) ensuring encounter data issues are resolve according to regulatory timeframes and health plans guidelines.
This position does not supervise anyone.
ESSENTIAL JOB FUNCTIONS:
- Work with IT to ensure health plan encounter data meet industry and individual health plan requirements
- Contact for health plans regarding encounter data submissions, serving as a resource and liaison.
- Using Microsoft SQL, analyzes and interprets encounter data to identify potential issues and trends.
- Coordinate and perform the correction of data rejections so that files may be resubmitted, error free.
- Monitor daily administrative duties of Encounter Data. This includes direct response to external and internal customers’ issues which may arise, ensuring resolution to customer satisfaction.
- Conduct monthly reconciliation audit of encounter data submissions by IT.
- Maintain clear documentation of encounter data workflow by health plan and submission method.
- Responsible for oversight of encounter data enhancements to include: identification, recommendation, coordinating request and implementation of enhancement(s) to ensuring compliance.
- Supports department projects/tasks as they arise. This includes generating standard and ad-hoc reports, managing contact list, and monitoring metrics.
- Develops encounter data high level workflows, including process by individual line of business.
- Facilitates regularly scheduled Encounter Data Workgroup meetings.
- Contribute to team effort by accomplishing related results as needed.
Accept and perform other duties as assigned.
QUALIFICATIONS & REQUIREMENTS:
- Job related Knowledge, Skills, and Abilities, including Documentation, if pertinent.
Minimum of four years experience in operations, data analysis, or information management - in healthcare industry is strongly preferred.
Minimum of two years analytical experience in a support role is preferred
- Creative, Problem-solving, and Innovation Skills.
Strong oral and written communication skills. Ability to clarify policies. Relies on extensive experience and judgment to plan and accomplish goals. Ability to work independently, organize and prioritize work. Must be able to demonstrate the ability to make decisions and resolve issues.
- Customer Focused and Communication Skills.
Ability to communicate and work well with internal and external customers. Independent decision making skills and demonstrated ability to take initiative to resolve issues.
SKILLS AND ABILITIES:
- Strong understanding of the healthcare environment and IT infrastructure is preferred
- Have EDI, HIPAA and Healthcare expertise with business and technical expertise
- In-depth knowledge of X 12 EDI formats and structures, EDI technology options and EDI data exchange implementation, CAQH regulations and core requirements and trading partner management oversight
- Must have knowledge of healthcare administrative functions, including claims processing, remittance advice processing, eligibility, verifications, etc.
- Understanding of CMS Risk Adjustment & HCC Methodology preferred
- Current and progressive healthcare experience in both provider and payer domains
- Must have Government billing regulations experience, including; Medicare, Medicare Managed Care, and Medical Terminology
- Excellent analytical, problem-solving and writing skills
- Strong database and MS skills, including queries and, spreadsheet
PERSONAL ERGONOMICS:Complies with policies and procedures, equipment orientation and workspace set up to ensure personal safety and well being as it relates to ergonomically sound usage, reporting immediately to management any complications or difficulties regarding appropriate usage of workplace and equipment.
OTHER CRITERIA: Motivated individual desired who takes initiative and approaches work with enthusiasm in a team environment. Complies with policies and procedures; performs job professionally with respect to others, to property, and to individual safety; works effectively with others to encourage teamwork and productivity. Maintains strict confidence of client information, ensuring client's privacy, and does not discuss internal business with external entities.