The Encounter Data Analyst is responsible for documenting, monitoring, analyzing the encounter process including inbound and outbound transactions ensuring compliance with regulatory and health plan requirements.
- Manage the encounter submission process including the outbound encounter process of Hoag Clinic’s encounter submission to the health plans and inbound encounter process of provider submission of claims to Hoag Clinic
- Meet and maintain encounter performance metrics as per regulatory guidelines and health plan requirements
- Coordinate root-cause-resolution of encounter data issues and errors by partnering with key stakeholders including providers, health plans, clearing house, Hoag IT, Claims Operations, etc. with appropriate reporting, documentation, and monitoring
- Assist with identifying and resolving health plan rejections along with managing communication with the clearinghouse and the health plans
- 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.
- Owns and maintains the desktop procedures, workflows and policy and procedure documents for encounters
- Identify and resolve health plan rejections daily along with managing all communication with clearinghouses and health plans.
- Develop weekly and/or monthly activity reports as well as audit reports for management to facilitate performance and process improvement.
- Interact in a positive and collaborative manner. Alert the claims management team of issues and trends observed in encounter processing, cost containment, and escalated claim issues
- Subject matter expert in a variety of knowledge sets and process improvement activities
- Perform other duties as assigned
Education, Training and Experience
Required: High School Diploma or equivalent, 3 years of experience in HMO encounter end-to-end process, knowledge of HMO/managed care regulatory guidelines
Experience with Epic Tapestry system, ClearIQ (TransUnion) clearinghouse, PRNLINK, and Encoderpro
Strong background in X12/ANSI HIPAA and EDPS requirements
Working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.) claims processing, fee schedules, coding categories (CPT, ICD, etc.)
Skills or Other Qualifications
Microsoft Word, Excel, Access, PowerPoint
Knowledge in SQL Server
Proficiency in running data queries and data analysis
Strong moral compass and commitment to Hoag’s values
Motivated to learn, continually improve and operate to one’s fullest potential
Positive attitude, passionate, excited, strong desire to simplify processes.
Experience in providing excellent customer service, empathetic ability
Skills to multi-task and manage competing priorities, apply critical thinking to solve problems
Tech savvy and posses a capability to quickly learn new applications
Ability to maintain composure and compassion while addressing a high volume of competing tasks
Comfortable with ambiguity and open to collaborative environments
License and Certifications