Enrollment and Encounter Data Analyst

Upper Peninsula Health Plan•Marquette, MI

6d•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 also researches, interprets, analyzes, and corrects pended and rejected Medicaid and Medicare encounters, including complex encounter issues, in accordance with contract guidelines. This position works with enrollment and encounter transactions, payment reconciliation, claims and encounter vendors, internal departments, providers, members, and government agencies. It supports accurate and timely data submissions, investigates discrepancies, contributes to audits and compliance reviews, maintains documentation, and protects confidential client data.

Requirements

Associate degree in health information processing, computer information systems, accounting, business, or a related field; five years of relevant experience may be considered in lieu of a degree.
Two to four years of claims management, information systems, accounting, or relevant experience.
Keyboarding proficiency and working knowledge of Microsoft Office, including Word, Excel, Access, and PowerPoint.
Excellent interpersonal relations and oral and written communication skills.
Excellent organizational abilities and attention to detail.
Medical terminology knowledge.
Ability to work independently and prioritize tasks with minimal supervision.
Ability to enter and access information from a computer and access all areas of the UPHP offices.
Ability to occasionally lift supplies or equipment, sit for prolonged periods, and perform manual dexterity tasks.

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 and 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, and safety standards, while maintaining sensitivity to confidential information.
Ensure the integrity and accuracy of enrollment and encounter processes by analyzing potential system issues with 834 and 837 transactions.
Serve as the subject matter expert and liaison for 834 audits and daily file reconciliations with the Michigan Department of Health & Human Services (MDHHS), and participate in enrollment and encounter workgroup meetings as needed.
Reconcile payment transactions with enrollment records by analyzing potential 820-record system issues, including monthly missing and overpayment reports; collaborate with Finance to resolve capitation payment rate issues.
Submit Medicaid service requests through CHAMPS to MDHHS regarding enrollment or payment discrepancies, MICH discrepancies, and immediate access-to-care issues between CMS and MDHHS.
Oversee work with the encounter vendor and internal staff to support accurate, timely encounter submissions; analyze and resolve claim pends and rejections for acceptance at CMS and MDHHS.
Liaise with business partners on 837 encounter data requirements, including 999 and 277CA acknowledgment files, ETRR (4950, 6502, 6503) files, and MAO-002.
Resolve day-to-day verbal and written inquiries about enrollment, encounter, and newborn activities from staff, providers, and members; work with claims and pharmacy staff to assess and confirm incoming enrollment, provider, and claims data is accurate and complete.
Review and reconcile the weekly out-to-hospital (OTH) movements report; compile, reconcile, document, and notify Wisconsin Medicaid and apply for Wisconsin Medicaid in a timely manner 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 processes that generate member ID cards, new member packets, PPD, EOC, Formulary Requests, and Medicaid Handbooks; ensure accurate and 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 required by MDHHS or CMS.
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 within the 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.