Encounter Data Analyst

Company: PacificSource Health Plans
Location: Bend
Posted on: January 9, 2021

Job Description:

Looking for a way to make an impact and help people?Join PacificSource and help our members access quality, affordable care!PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.Position Overview: Review, analyze and adjust hospital and professional claims as necessary for Encounter resolution. Research Encounter Edit, identify trends and resolve root cause, which need a higher level of adjudicator expertise, EDI interpretation and decision making for Government lines of business. Contribute to establishing and/or revising claims research policies and procedures and look for ways to improve processes. Work with external vendors contracted for EDI transmissions. Participate in Encounter work groups, across departments and participate or lead other standing or ad hoc workgroups as needed.Essential Responsibilities:

• Analyze weekly Encounter pend/rejection reports, drilling down to root cause, system improvement opportunities and/or EDI transaction errors.
  • Review data for trends
  • Adjust claims as needed for pend resolution
  • Collect data and present findings to the Government Encounter team
  • Work cooperatively with internal departments and external vendors to review research to appropriately resolve Encounter errors based on PacificSource policy and procedures and applicable laws governing claims processing.
  • Work independently under time pressure and maintain company compliance by resolving and processing claims within the established by regulatory agencies and the plan timelines, and according to the processes established by the plan.
  • Manage quarterly OHA required Sterilization Consent Audit within timeframe provided.
    • Request medical records as applicable
    • Adjust claims as necessary
    • Search internal systems for Consent form on file
    • Process OHA Deceased Client Report (DCR) within 14 day timeframe.
      • Adjust claims as necessary
      • Process OHA Client Not Enrolled report within timeframe provided.
        • Adjust claims as necessary
        • Work miscellaneous OHA requests and/or reports as applicable to Encounter Data.
        • Review and resolve claim and system edits using multiple systems, processes and procedures.
        • Responsible for entering detailed system notes to record pertinent information involving a claim adjustment.
        • Document and report issues that affect claims processing or accuracy to the Government Operations Manager.Supporting Responsibilities:
          • Develop and track project plans for large upcoming projects that affect multiple areas.
          • Ability to judge severity of problems and the need to escalate to management or employ external services.
          • Maintain professional, service oriented relationships.
          • Demonstrate ability to organize and prioritize work.
          • Provide Claims processing assistance to the Claims Department when available.
          • Report pertinent information back to the Claims Leadership Team.
          • Perform other duties as assigned.Work Experience: Minimum five years claims adjudication experience with strong knowledge of Government requirements or equivalent work experience in a related health field. Coding experience is required. EDI knowledge is preferred.Education, Certificates, Licenses: High school diploma or equivalent required.Knowledge: Intermediate proficiency in Microsoft Office Applications including Word and Excel. Basic knowledge of medical terminology and medical coding preferred. Knowledge of claims and provider network preferred. Intermediate knowledge of Government Programs (Medicare/Medicaid) structure preferred. Intermediate understanding of EDI files and 5010 requirements. Excellent Time Management, Critical Thinking and Research skills preferred.Competencies
            • Adaptability
            • Building Customer Loyalty
            • Building Strategic Work Relationships
            • Building Trust
            • Continuous Improvement
            • Contributing to Team Success
            • Planning and Organizing
            • Work StandardsEnvironment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.Our Values
              • We are committed to doing the right thing.
              • We are one team working toward a common goal.
              • We are each responsible for customer service.
              • We practice open communication at all levels of the company to foster individual, team and company growth.
              • We actively participate in efforts to improve our many communities-internally and externally.
              • We encourage creativity, innovation, and the pursuit of excellence.
              • We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

Keywords: PacificSource Health Plans, Bend , Encounter Data Analyst, Professions , Bend, Oregon