Job Details

Central Coast Salary Range: $76,466/year - $110,875/year

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

This position is responsible for providing data collection, analytical, reporting and project management support to the Claims Operations team related to the processing, correction and transmission of highly accurate encounter data. Validates and analyzes reports and logs related to the processing of encounter transactions to ensure compliance, accuracy, completeness and timeliness, as well as continuous process improvement.

Duties and Responsibilities

• Adhere to regulatory and internal guidelines in conjunction with CenCal Health policies and procedures as they apply to both internal and external encounter reporting
• Perform data analysis of submitted encounter data files from external entities and produce regular reports of findings
• Measure Encounter data accuracy file submissions and correction timeliness against established contractual obligations, based on findings, make recommended procedural changes to ensure these guidelines are met
• Monitor and analyze encounter data reporting of encounter data
• Maintain a thorough knowledge of CenCal Health's encounter data reporting requirements
• Analyze, interpret, and summarize encounter data for development of solutions for reducing and mitigating errors
• Analyze existing and future encounter submission regulatory guidelines to ensure compliance with system editing logic
• Work in conjunction with the IT department on encounter data issues and process development related to successful encounter management
• Work cooperatively on ongoing Encounter Data Process Improvement projects with other CenCal Health departments as well as external vendors and Provider Community
• Develop system Change Forms (SCFs) to improve Encounter Data Quality and prevent rejections
• Assist with monitoring and oversight and ensure contractual obligations of our outsourced Encounter data processing vendor requirements are met. Assist with the plan and develop changes when necessary. Recommend corrective action to resolve processing and data issues
• Review, manage and process encounter data for the supplemental file program, including error review and resubmission when necessary
• Management of downstream delegate (VTS) encounter data including working with Vendor, sharing errors from CMS, then receiving and resubmitting the corrections provided by Vendor back to CMS
• Maintain spreadsheets for reporting of encounter related projects both within the department as well as companywide and with the outsourced vendor
• Review each error received from CMS and make corrections; develop new processes to prevent future errors
• Work with IT to correct encounter data errors during pre-submission review
• Work with internal staff and/or create process improvements to prevent encounter data errors
• Develop and report on Encounter Data for Claims Quality Committee (CQC), Delegation Oversite Committee and delegated vendors (VTS) JOC meetings
• Manage encounter data counts/charts for ECM/CS program
• Attend internal and external meetings when necessary
• Adhere to all CenCal Health employee policies and procedures, and meet required performance standards
• Other duties as assigned

• Technical knowledge related to claims/encounter data including understanding of primary coding systems (e.g., CPT/HCPCS, ICD-10, NDC)
• Ability to diagnose problems with EDI processes by working effectively with internal departments and third parties
• Assist in the formulation of policies and procedures related to the encounter data process; understand and interpret policies, procedures and regulations
• Proficient in use of MS Office applications, Excel, and Word and/or SQL
• Knowledge of data analysis methods used in the encounter/claim submission process
• Knowledge of CMS and Medi-Cal program guidelines, regulations and data reporting requirements desired
• Analytical and problem-solving skills
• Excellent verbal and written communication skills
• Team player who builds effective working relationships

• Knowledge of the Medicare D-SNP program
• Strong knowledge in dual eligible encounter processing (Medi-Cal and Medicare D-SNP)
• Cognizant EDM application system experience
• Bachelor's degree in health care administration, Business Administration or related fields preferred
• Two-three (2-3) years in data analysis in a managed health care environment; claims experience is highly desirable
• Any combination of education, training and experience that would provide an equivalent background
• Experience in healthcare system configuration
• Experience in analysis
• Must be proficient in the MS Suite of software and have intermediate-advances skills in Excel
• Familiarity with database systems

• QNXT experience is helpful
• Medicare Claims processing knowledge in QNXT