Senior Encounters Analyst

Highmark Health • PA, Working at Home - Pennsylvania, PA

2d • $72,700 - $116,600 • Hybrid

About The Position

This job ensures that services provided to health plan members and billed by providers to the health plan are submitted to respective State agencies and CMS accurately and timely. Ensures accuracy of complex data with minimal errors to further ensure that health plan medical expense on file at respective State and CMS is complete and up to date. Completes complex root cause analysis and research of errors to generate corrections in a timely manner to provide an accurate picture of medical expense and avoid penalties from the State and/or CMS. Provides guidance and education to lower level employees. This is a remote based role however will need to go onsite 1 day a month.

Requirements

• 5 - 7 years in Encounters, Claims Processing or Claims Billing
• Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
• Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
• Demonstrated organizational skills
• Ability to work independently
• Ability to work as part of a team
• Ability to work in a fast paced environment with changing priorities
• Demonstrated written communication skills
• Demonstrated interpersonal/verbal communication skills
• Demonstrated research skills
• Demonstrated detail orientation
• Understanding of AHCCCS and CMS rules/regulations including encounter process
• Health/Medical Programs
• HIPAA
• Outlook
• Microsoft Office
• Microsoft Excel

Nice To Haves

• SQL and SAS experience.

Responsibilities

• Actively participate in decision making process and documentation for meeting Service Level Agreements (SLA) set by respective states of operation
• Lead regular meetings with Internal and External Clients/Vendors to review projects globally, coordinate collaborative efforts and knowledge sharing among all team members, seeking opportunities to leverage existing processes.
• Analyze and research complex encounter errors to identify root cause(s) and make recommendations for resolution.
• Research and document all encounter errors in established database(s).
• Communicate regularly with management on issues discovered through research efforts.
• Communicate with and provide clear, detailed, effective documentation to other departments within the organization on issues causing encounter pends/denials and potential solutions.
• Handle reversals / recoupments resulting from encounter errors.
• Produce monthly summary reports identifying adjudication errors.
• Other duties as assigned or requested.

Benefits

• Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED