Business Encounter Data Analyst

Unclassified - Boston, MA

Full-time - Mid Level

Remote - Boston, MA

10,001+ employees

About the position

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.

Responsibilities

• Understand the claims encounter data requirements in detail to ensure claims data is complete, accurate, and timely.
• Review encounter rejections and provide resolution of minor to complex data/system issues or processes.
• Develop and maintain supporting business processes and workflows.
• Recognize inconsistencies and gaps to improve productivity, accuracy, and data usability, and streamline procedures and policies.
• Provide critical analysis of functional performance and make recommendations for enhancements and process improvements.
• Build, sustain, and leverage relationships to allow for continuous improvement of the encounter data business process.
• Provide encounter data support to vendors and ensure understanding of regulatory encounter requirements.
• Participate in claims encounter initiatives, working with IT and other internal departments to automate claims encounters functions.
• Understand how claims payment methodologies, adjudication processing, and CMS and State encounter regulations interrelate to maintain compliant encounter reconciliation processes and SLAs.
• Stay current with the needs and operations of the regulatory deliverables.
• Interact with business stakeholders to understand new business requirements and enhancement requests.
• Provide business encounter subject matter expertise for internal departments and both CMS and State agencies.

Requirements

• Bachelor's Degree in a related field or equivalent combination of training and experience.
• 5 or more years' experience in a fast-paced, managed healthcare environment.
• 5 or more years' experience with encounter data operations, claims processing, and/or provider billing.
• 3 or more years of claim coding and billing processes, including CPT, ICD-10, and HCPCS coding.
• Advanced knowledge of HIPAA regulations and 837 EDI standards.
• Experience working with Medicaid, Medicare, or commercial encounter, coding, and/or regulatory guidelines.

Nice-to-haves

• AHIMA or other nationally recognized Coding/Billing Certification.
• Experience with Edifecs encounter data software.
• Experience with Cognizant Facets claim adjudication system.
• Experience with industry standard payment rules and methods.

Benefits

• Full-time remote work
• Competitive salaries
• Excellent benefits