Encounter Data Analyst
Company: PacificSource Health Plans
Posted on: January 9, 2021
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
- Review data for trends
- Adjust claims as needed for pend resolution
- Collect data and present findings to the Government Encounter
- 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
- Adjust claims as necessary
- Process OHA Client Not Enrolled report within timeframe
- Adjust claims as necessary
- Work miscellaneous OHA requests and/or reports as applicable to
- 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
- 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
- Report pertinent information back to the Claims Leadership
- 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
- 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
- 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
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