Unclassified - Boston, MA
posted 2 months ago
It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. The Business Encounter Data Analyst is responsible for compiling and analyzing encounter data and understanding the claim impact of changes and decisions to the business process to ensure that CMS and State Service Level Agreements (SLAs) are achieved. This individual will support the encounter data lifecycle process working closely with business and technical resources as well as document and illustrate business requirements, processes, and deficiencies across the organization, our vendors, and our regulators. The role requires a deep understanding of the claims encounter data requirements to ensure that claims data is complete, accurate, and timely. The analyst will be responsible for reviewing encounter rejections and providing resolutions for minor to complex data/system issues or processes. Additionally, they will develop and maintain supporting business processes and workflows, recognize inconsistencies and gaps to improve productivity, accuracy, and data usability, and streamline procedures and policies. Critical analysis of functional performance will be necessary, along with making recommendations for enhancements and process improvements. Building and sustaining relationships is key to allowing for continuous improvement of the encounter data business process. The analyst will provide encounter data support to vendors and ensure understanding of regulatory encounter requirements. Participation in claims encounter initiatives, such as working with IT and other internal departments to automate claims encounters functions, is also a significant part of the role. Understanding how claims payment methodologies, adjudication processing, and CMS and State encounter regulations interrelate is essential to maintain compliant encounter reconciliation processes and SLAs. The analyst will stay current with the needs and operations of the regulatory deliverables and interact with business stakeholders to understand new business requirements and enhancement requests. They will also provide business encounter subject matter expertise for internal departments and both CMS and State agencies, ensuring performance for timely and accurate reviews meets or exceeds internal, CMS, and State SLA requirements.