The Claims and Encounter Analyst I supports the claims department by analyzing data, refining processes, and ensuring compliance with State, CMS, and contractual guidelines.
Responsibilities include conducting in-depth claims analysis and root cause investigations, validating DRG grouping and pricing outcomes with knowledge of HCC and ICD-10, reviewing claim and encounter data for completeness and compliance, analyzing trends in encounter rejections and denials, maintaining encounter data submission workflows to support audits, developing monthly provider scorecards, assisting in Provider Claims Appeals, working with vendors to improve claims processes, preparing data for state and federal inquiries, evaluating SLAs with the claims TPA, ensuring accurate refund processing, analyzing patient and medical information for Coordination of Benefits and other conditions, coordinating with Finance on provider payments, investigating claims adjudicated by Third-Party Administrators, developing business intelligence solutions and reporting using SQL Server, Tableau Server, Power BI, analyzing data quality, developing reports for process and trend analysis, and collaborating with business users and data teams to maintain ETL mappings.
Schedule: 8:30 AM – 5:30 PM, 40 hours per week.
Bachelor's degree required, preferably in a quantitative discipline. Certified Professional Coder is a plus.
3-5 years healthcare experience preferred, preferably in managed care.
Proficiency in analytics tools such as SAS, SQL.
Experience with claims adjudication, knowledge of Medicaid, Medicare benefits, CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS.
Proficient in MS Excel, Word, PowerPoint and claims processing systems or comparable databases.
Effective communication and interpersonal skills.
Ability to multitask, strong organizational skills, detail-oriented, professional, and a team player.
Physical ability to perform job duties including standing, sitting, lifting up to 50 pounds, bending, walking, and fine motor skills.
Location
New York, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$70,000 - $90,000
Remote work allowed
No
Posted
3 weeks ago