Senior Analyst Encounter (Medicare)
About The Position
The EDI senior analyst is responsible for monitoring, analyzing, validating, and reconciling Encounter transactions supporting operations and regulatory reporting. This position serves as a key liaison between Claims, Risk Adjustment, Enrollment, IT, Finance, and compliance teams to ensure that Encounter data received is complete, accurate, timely, and appropriately reflected in downstream reporting. The analyst will trace Encounters from their original source through systems and ultimately to applicable regulatory submissions, including CMS and, where applicable, AHCA requirements. The position will investigate discrepancies, identify root causes, document findings and coordinate corrective actions.
Requirements
- Bachelor’s degree in information technology, Health Information Technology, Business Analytics, Computer Science, Healthcare administration or related field.
- 2+ years of experience working with EDI, Healthcare data, encounters, and claims.
- Experience working with Medicare Advantage data, CMS reporting, and requirements.
- Strong SQL skills.
- Experience with data reconciliations, validation, and root-cause analysis.
- Ability to trace data across multiple systems.
- Strong excel/data analysis skills
- Strong documentation and analysis skills.
- Attention to detail.
Responsibilities
- Monitor incoming and outgoing encounter transactions.
- Review EDI files and transactions for completeness, accuracy, errors, and missing information
- Analyze EDI transaction data through the organization’s systems to determine how the information was processed.
- Reconcile EDI data against membership, claims, encounters, providers, and other source systems
- Establish and maintain data lineage between encounter sources and CMS and other regulatory entities
- Evaluate CMS submission files and reports to identify discrepancies, rejections, errors, and data inconsistencies.
- Track EDI-related issues through resolution and maintain appropriate documentation and audit trails
- Work with appropriate teams to resolve issues
- Develop and maintain reconciliation reports, exception reports, dashboards, and tracking logs.
- Identify recurrent data quality issues and recommend process or systems improvements.
- Support regulatory audits
- Maintain knowledge of regulatory data requirements, specifications, and submission process.
- Ensure issues are escalated properly and resolved.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
