Job Summary

The Lead Analyst, Encounters is responsible for leading large projects and initiatives across multiple markets and states to improve overall encounter performance. Oversees end-to-end encounter workflow specific to CMS Risk Adjustment programs and takes the lead on training and mentoring new team members.

The Lead Analyst, Encounters drives process improvements and system enhancements and uses advanced knowledge of healthcare data, systems, and operational processes to serve as subject matter experts across multiple domains to support growth and improvement initiatives for encounters. Maintains expert level knowledge of regulatory requirements and business significance of encounters. At the direction of the Manager, Encounters, drives resolution of issues and oversees activities related to encounter submission performance optimization across multiple markets and states.

 

Job Duties

• Leads and drives operational performance improvement initiatives

• Monitors encounter submissions across multiple markets or states

• Provides guidance to Encounters Analysts on operations, processes, and systems

• Serves as subject matter expert in support of encounters performance improvement initiatives which may include upstream claims, member, providers, vendors, inbound and outbound processes, and error corrections

• Engages with IT, health plans, and regulators to resolve issues and optimize encounters performance

• Performs root cause analysis of claims/encounters processing and submission issues; develops recommendations based on data and industry knowledge. Collaborates across departments to design and implement systems changes to meet encounter data processing and submission goals. 

• Analyzes data to verify outcomes of initiatives

• Develops reports and distributes them to appropriate departments for error resolution, follow up, and performance monitoring. 

• Monitors vendor encounter submissions, contractual compliance, and SLAs

 

Job Qualifications

REQUIRED EDUCATION:

Bachelor’s Degree or equivalent experience

 

EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

7 or more years of experience in billing, claims, encounters, and data analysis  5 or more years of managed care experience  Expert knowledge of healthcare encounters Advanced data analysis skills and experience writing basic to advanced SQL  Strong interpersonal and communication skills Proficient with verbal and written presentation of complex operational information

 

PREFERRED EXPERIENCE:

Health data analysis and reporting, project management, working with various levels of management throughout multiple organizations  Leading analysis and/or operational teams in managed care 

CMS Risk Adjustment program submission experience highly preferred