CareSource
Job Summary
This position supports TRICARE Prime Demo by CareSource Military & Veterans, which aims to enhance healthcare access and prioritize the unique needs of the military community. We encourage military affiliated individuals, veterans, military spouses, and those with prior TRICARE experience to apply.
The Encounters Systems Analyst III is responsible for compiling and analyzing Encounters data and understanding the financial and clinical impact of changes and decision to the business process to ensure that Service Level Agreements are achieved.
Essential Functions
Compile and analyze Encounter data. Understand the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements (SLAs) are achieved
Provide analytical support and leadership for Claims Encounters Regulatory Data projects
Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes
Provide Claims Encounter Subject Matter Expertise (SME) for both CMS and State agencies and internal CareSource impacted organizations (IT, Claims, New Business, Enrollment, etc.)
Build, sustain and leverage relationships with persons within his/her responsibility to constantly allow for continuous improvement of the Encounter Data business process
Direct responsibility for the design, testing and delivery of supporting processes to the business
Lead the claims data processes to ensure accuracy and compliance with CMS and state agencies
Provide support for other key claims data management and readiness to state and governing entities
Understand the Claims Encounter Data requirements in detail to enable one to lead efforts to ensure claims data submissions achieve the required SLAs through requested changes internally and externally
Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies
Responsible for Claims Encounters regulatory reporting
Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
Prepare and monitor various management and oversight metrics and reports as required
Lead Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with SIS
Provide support of vendors, managing SLA's, regulatory requirements and contractual metrics
Maintain positive and strategic relationships with internal and external stakeholders
Contribute to and/or develop user stories or provide user story guidance for sprint planning
Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLA's
Perform any other job duties as requested
Education and Experience
Military affiliation or TRICARE experience is preferred.
Bachelor's degree or equivalent years of relevant work experience is required
Master's degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred
Minimum of five (5) years of managed healthcare, claims, or managed care regulated environment experience is required
Minimum of five (5) years of experience using at least two of the following tools is required: SQL, SAS, SSIS, MySQL, ORACLE, R, or PowerBI
Competencies, Knowledge and Skills
Knowledge of relational databases (SQL Server, Oracle, etc.)
Experience with SQL Server - 2016 or newer
Strong database querying, data analysis and trending skills
Edifecs knowledge is preferred
Demonstrated understanding of claims operations specifically related encounters
Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Knowledge of Claims IT processes/systems
Knowledge of claims analytic processes/systems
Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
Experience with 837O files to States and/or CMS (MA EDS) preferred
Experience with 835 files preferred
Excellent communication skills; both written and verbal required
Ability to work independently and within a team environment
Time management skills; capable of multi-tasking and prioritizing work
Attention to detail
Critical thinking and listening skills
Licensure and Certification
None
Working Conditions
General office environment; may be required to sit or stand for extended periods of time
Compensation Range $81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type Salary
Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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The Encounters Systems Analyst III is responsible for compiling and analyzing Encounters data and understanding the financial and clinical impact of changes and decision to the business process to ensure that Service Level Agreements are achieved.
Essential Functions
Compile and analyze Encounter data. Understand the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements (SLAs) are achieved
Provide analytical support and leadership for Claims Encounters Regulatory Data projects
Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes
Provide Claims Encounter Subject Matter Expertise (SME) for both CMS and State agencies and internal CareSource impacted organizations (IT, Claims, New Business, Enrollment, etc.)
Build, sustain and leverage relationships with persons within his/her responsibility to constantly allow for continuous improvement of the Encounter Data business process
Direct responsibility for the design, testing and delivery of supporting processes to the business
Lead the claims data processes to ensure accuracy and compliance with CMS and state agencies
Provide support for other key claims data management and readiness to state and governing entities
Understand the Claims Encounter Data requirements in detail to enable one to lead efforts to ensure claims data submissions achieve the required SLAs through requested changes internally and externally
Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies
Responsible for Claims Encounters regulatory reporting
Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
Prepare and monitor various management and oversight metrics and reports as required
Lead Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with SIS
Provide support of vendors, managing SLA's, regulatory requirements and contractual metrics
Maintain positive and strategic relationships with internal and external stakeholders
Contribute to and/or develop user stories or provide user story guidance for sprint planning
Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLA's
Perform any other job duties as requested
Education and Experience
Military affiliation or TRICARE experience is preferred.
Bachelor's degree or equivalent years of relevant work experience is required
Master's degree in Science/Arts is preferred; concentration in Healthcare Analytics or Data Science preferred
Minimum of five (5) years of managed healthcare, claims, or managed care regulated environment experience is required
Minimum of five (5) years of experience using at least two of the following tools is required: SQL, SAS, SSIS, MySQL, ORACLE, R, or PowerBI
Competencies, Knowledge and Skills
Knowledge of relational databases (SQL Server, Oracle, etc.)
Experience with SQL Server - 2016 or newer
Strong database querying, data analysis and trending skills
Edifecs knowledge is preferred
Demonstrated understanding of claims operations specifically related encounters
Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Knowledge of Claims IT processes/systems
Knowledge of claims analytic processes/systems
Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
Experience with 837O files to States and/or CMS (MA EDS) preferred
Experience with 835 files preferred
Excellent communication skills; both written and verbal required
Ability to work independently and within a team environment
Time management skills; capable of multi-tasking and prioritizing work
Attention to detail
Critical thinking and listening skills
Licensure and Certification
None
Working Conditions
General office environment; may be required to sit or stand for extended periods of time
Compensation Range $81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type Salary
Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
#LI-RW1
#J-18808-Ljbffr