Enrollment and Encounter Data Analyst

Upper Peninsula Health Plan•Marquette, MI

8d•Onsite

About The Position

The Enrollment and Encounter Data Analyst compiles, analyzes, trends, tracks, and interprets Medicare-Medicaid Plan, Medicaid, and TPA enrollment activities. The role researches, interprets, analyzes, and corrects pended and rejected Medicaid and Medicare encounters, including complex encounter issues, in accordance with contract guidelines. It ensures the accuracy and integrity of enrollment, payment, and encounter data and coordinates with internal departments, government agencies, vendors, providers, members, and business partners. The analyst oversees enrollment and encounter processes, reconciles enrollment and payment records, resolves encounter claim pends and rejections, and supports required submissions and compliance reviews. The role also manages related member material mailings, handles inquiries, documents work, and maintains confidentiality of client data. The position works in office conditions, may require occasional travel, and involves exposure to clients and others, frequent interruptions, and prolonged sitting.

Requirements

Associate degree in health information processing, computer information systems, accounting, business, or a related field; five years of relevant experience may be substituted for a degree.
Two to four years of claims management, information systems, accounting, or relevant experience.
Keyboarding proficiency and working knowledge of Microsoft Word, Excel, Access, and PowerPoint.
Excellent interpersonal skills and oral and written communication skills.
Excellent organizational abilities and attention to detail.
Knowledge of medical terminology.
Ability to work independently and prioritize tasks with minimal supervision.

Nice To Haves

Bachelor’s degree in health information management, computer information systems, accounting, or a related field.
Four to six years of experience reporting, analyzing, interpreting, and presenting data.
Experience analyzing large data files and performing file reconciliations.
Knowledge of CPT, HCPCS, and ICD-10 coding; revenue codes; DRG, UB-04, and CMS-1500 claims submission; electronic claims submissions; APC reimbursement methodology; and MSA and CMS policy.
Orientation to managed care and health care systems.

Responsibilities

Follow established UPHP policies and procedures, objectives, safety standards, and confidentiality requirements.
Ensure data integrity and accuracy in enrollment and encounter processes by analyzing potential system issues involving 834 and 837 transactions; serve as the subject matter expert and liaison for 834 audits and daily file reconciliations with MDHHS; participate in enrollment and encounter workgroup meetings as needed.
Reconcile payment transactions to enrollment records by analyzing potential issues with 820 records, including monthly missing and overpayment reports; collaborate with Finance to resolve capitation payment rate issues.
Submit Medicaid service requests through CHAMPS to MDHHS concerning enrollment or payment discrepancies, MICH discrepancies, and immediate access-of-care issues between CMS and MDHHS.
Coordinate with the encounter vendor and internal staff to ensure accurate and timely encounter submissions; analyze and resolve claim pends and rejections for acceptance at CMS and MDHHS; liaise with business partners regarding 837 encounter data requirements and related acknowledgment and reporting files.
Resolve day-to-day verbal and written inquiries regarding enrollment, encounter, and newborn activities from staff, providers, and members; work with claims and pharmacy staff to assess and confirm the accuracy and completeness of enrollment, provider, and claims data.
Review and reconcile the weekly out-to-hospital movements report; compile, reconcile, document, and notify Wisconsin Medicaid, and apply for Wisconsin Medicaid on behalf of the TPA client, Wisconsin Department of Corrections, while members are inpatient.
Verify and reconcile Maternity Case Rate payments for qualifying births and ensure newborns are appropriately enrolled with UPHP.
Serve as Domain Administrator for CHAMPS.
Oversee generation of member ID cards, new member packets, PPD, EOC, Formulary Requests, and Medicaid Handbooks; ensure accurate, timely mailings; validate print-vendor mailings, verify invoices, and ensure vendor compliance with the contract.
Work with the Senior Programmer to interpret, analyze, test, and validate changes to 834 enrollment and 837 encounter files to accommodate MDHHS and/or CMS requirements.
Serve as the enrollment and encounter data subject matter expert for audits and compliance reviews.
Work with the Risk Adjustment Analyst and Coding Compliance Auditor to interpret and correct errors in Encounter Data Processing Systems (EDPS).
Work with the Compliance Department and external vendors to identify and validate accurate claim encounter activity for Program Integrity submissions to MDHHS.
Maintain written documentation of activities and revise procedures and policies to improve efficiency and accommodate changes.
Maintain confidentiality of client data.
Perform other related duties as assigned or requested.