The Encounter Analyst II is responsible for managing inbound and out bound files in the encounter management workflow, including monitoring and tracking sub-delegate file submissions, and providing insight and assistance with process issues.
The position will require limited travel to the home office, located in Morrisville, NC, for meetings and training as needed. New hire employee training will be in Morrisville for up to 3 weeks.
Responsibilities & Duties
Manage encounter/claims files
- Monitor and track outgoing 837 files to NC Tracks and EPS
- Monitor and track incoming 999 and 835 files from NC Tracks
- Monitor and track incoming XML files from EPS
- Track rebill files submitted by Encounter Team
- Monitor and track carve out files (separately from others) for TCM and Maternity services
- Conduct file transfers as needed, ensuring all files get to all appropriate locations through review and submission
- Monitor and track vendor files in the data warehouse
- Monitor and track vendor files in EPS
Conduct data analysis and report findings
- Monitor and Report Denial Trends for NC Tracks/EPS (Alliance and Vendors)
- Monitor and Report File submission trends for both Alliance and Vendors
Ensure accuracy, timeliness, and reconciliation of Service Level Agreement (SLA) files submitted
- Ensure accuracy of SLA files by monitoring the number of encounters sent upstream (by Alliance and vendors)
- Collect data on encounters that pass/fail (accept/error)- from vendor files compared to EPS representation
- Ensure timeliness of SLA file submission by monitoring and tracking files to ensure files are inclusive of all encounters and are sent within time limits
- Reconcile SLA files by monitoring and tracking paid amounts in the Encounter Processing System (EPS) for comparison against FRT values
- Monitor subdelegates’ (DME, Vision, NEMT, Pharmacy) file submissions and copies of files sent to the Alliance Claims Data Warehouse to ensure all are accounted for in a timely manner
Manage encounter denials
- Assist team in encounter denial management when necessary (Medicaid and State Funding)
Minimum Requirements
Education & Experience
High School diploma or equivalent and three (3) years of experience in claims/reimbursement or in the information systems departments of a healthcare or managed care environment.
Knowledge of NC Medicaid billing, EDI, Alliance Claims System, and EPS a plus.
Knowledge, Skills & Abilities
- Knowledge of the Encounter Companion Guide, Encounter Data Submission Guide and the Encounter Data Manual published by State of NC Department of Health and Human Services
- Knowledge of NC Medicaid and State billing requirements for physical and behavioral health claim processing and HIPAA guidelines
- Knowledge of Electronic Payments and Statements (EPS) edit codes
- Working knowledge of medical terminology, standard claim forms and coding
- Working knowledge of healthcare services
- Working knowledge of PC-based software programs or automated database management systems
- Working knowledge of common denials and courses for corrections
- Working knowledge of service authorizations, consumer eligibility, routine billing requirements and coordination of benefits
- Excellent written and verbal communication skills with the ability to understand oral and written instructions
- Proficient with Microsoft Office Products including Word, Excel and Power Point
- Ability to enter routine and repetitive batches of data from a variety of source documents with structure time schedules
- Ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-10, HCPCS and NDC) and revenue codes
Salary Range
$22.23 - $28.34/Hourly
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
• Medical, Dental, Vision, Life, Short and Long and Short Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility
United States
