Senior Encounters Analyst-2

Job ID: J138611
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 8, 2019

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Description

JOB SUMMARY

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.

ESSENTIAL 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.

EDUCATION

Required

  • High School Diploma/GED

Substitutions

  • None

Preferred

  • None

EXPERIENCE

Required

  • 5 - 7 years in Encounters, Claims Processing or Claims Billing

Preferred

  • None

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • 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

Language (Other than English)

None 

Travel Required

0%  - 25%


PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Frequently

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Summary

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.

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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