CLAIMS AND ENCOUNTER ANALYST II

C2Q Health Solutions • New York, NY

1d • Onsite

About The Position

The Claims and Encounter Analyst II enhances the efficiency and effectiveness of the claims department by analyzing data, refining processes, and ensuring compliance with State, CMS, and contractual guidelines. This role requires knowledge of Government Programs medical claims and authorization data analytics, encounter process, risk adjustment, and a strong focus on data-driven process improvement.

Requirements

• Bachelor's degree is required; quantitative discipline is strongly preferred.
• Three to five (3-5) years of managed care (Medicaid and Medicare) data analytics is required.
• Proficiency in data analytics, i.e. SAS, SQL, one or the other is required.
• Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software is required.
• Effective oral, written, and interpersonal communication skills are required.
• Able to multitask efficiently, effectively, and timely.
• Strong organizational skills and work ethic.
• Detail-oriented, professional and collaborative, a great team player.

Nice To Haves

• Master’s degree is preferred.
• Claims adjudication and understanding of claims PPS is strongly preferred.
• Knowledge of Medicaid and Medicare benefits, enrollment and billing, and provider contracting is strongly preferred.
• Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS is preferred.

Responsibilities

• Conduct in-depth claims analysis, root cause investigations, and identify process improvement opportunities.
• Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.
• Work with vendors to identify sources of opportunities to improve claims process for providers.
• Evaluate and revise SLAs with the claims TPA to improve operational efficiency; track and monitor open tickets and configuration updates.
• Leverage multiple data sources to develop scheduled and ad-hoc reports to enable process and trend analysis.
• Assist the Director with analytics to support Medicare risk adjustment process through advanced medical records review to identify and code all relevant diagnoses, including chronic conditions utilizing ICD-10 coding guidelines.
• Assists improve the risk adjustment surveillance process.
• Validate DRG grouping and pricing outcomes; possess basic knowledge of HCC and ICD-10.
• Analyze claims data to identify risk-adjustable conditions and uncover opportunities to improve risk capture processes through data-driven insights and recommendations.
• Review, validate, and reconcile claim and encounter data submissions for completeness, timeliness, and compliance.
• Analyze trends in encounter rejections and denials; develop improvement plans.
• Maintain the integrity of encounter data submission workflows and documentation to support audits.
• Work with department heads and business owners, collect and prepare data for state, federal, and internal inquiries (e.g., HPMS, IPRO), ensuring accuracy and regulatory compliance.
• Analyze and understand data from various source systems to validate data quality and ensure that business reporting needs are fulfilled through a formal, documented process.
• Prepare quarterly utilization metrics to support the timely and accurate submission of miscellaneous state reporting, i.e. PACEOR, VBPTR, MLR.
• Assist department heads and business owners in identifying and performing appropriate analyses to enable sound decision-making.
• Work with business users, report writers, Data Warehouse team, and enterprise data architect to refine/adapt/maintain ETL mappings as business users needs change or the data environment changes.
• Develop monthly provider scorecards to assess network provider performance and identify improvement areas.
• Perform in-depth analytics on provider performance against the Quality Incentive Program to ensure adherence and accurate incentive payments based on contracts.
• Coordinate with Finance on check runs, provider payments, and resolution of over/underpayments.
• Develop and deliver business intelligence solutions and associated reporting using various Enterprise Data Warehouse (EDW) applications and BI tools (specifically using SQL Server, Tableau Server, Power BI, etc.); revise reporting dashboards as needed.
• Other duties as assigned.

Benefits

• We are an affirmative action and equal opportunity employer.
• All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information.
• We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level