JOB SUMMARY

The Risk Adjustment Analyst Sr (Texas Medicaid Encounter Analyst) is responsible for monitoring and oversight of the end-to-end encounter management workflow. Supports program management activities around risk adjustment data management and submissions to government agencies such as Centers for Medicare and Medicaid Services (CMS) or Health & Human Services (HHS).

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SALARY (BASED OFF OF RELEVANT EXPERIENCE)

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The pay range for this position is $36.80 (entry-level qualifications) - $57.03 (highly experienced) The rate will depend upon the successful candidate’s qualifications and prior experience.

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ESSENTIAL FUNCTIONS OF THE ROLE

\n\nMonitors and oversees the end-to-end claims encounter management workflow.\nAnalyzes claims and supplemental data to identify reporting gaps, risk gaps, or sources of incorrect and incomplete diagnostic data.\nPerforms analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines.\nUsing data from internal and external sources, analyzes complex encounter inbound/outbound process issues to provide insight to decision-makers.\nResearches and documents encounter errors in established systems and databases with appropriate statistical trend analysis\nPerforms root cause analysis of encounters processing and submission issues and develops recommendations based on data and industry standards.\nPerforms various financial analysis such as revenue forecasting and ROI.\nContributes to program improvement by designing and implementing business process and system changes, collaborating to resolve encounter data and process issues and managing policy and procedure documentation.

KEY SUCCESS FACTORS\nAdvanced knowledge of SQL, MS Excel, MS Access, MS Word, MS Visio and MS PowerPoint.\n\nUsing SQL, able to design and run intermediate to complex queries and reports from multiple databases.\n\n\nAble to independently gather, interpret and analyze data for the purpose of identifying trends, problems and opportunities for improvement.\nDetailed knowledge of ICD_10, HCPCS, CPT Codes, Revenue Codes, UB04 and HCFA 1500 claim forms.\nProficient understanding of electronic processing of 837 and 835 as required.\nMust have thorough knowledge of complex claim processing.\nKnowledge of ACA, Medicaid, MCO, TPA business requirements preferred\nExcellent time management and organizational skills with the ability to handle multiple tasks in a timely and accurate manner.\nAble to work under pressure, adhere to deadlines and know when to escalate information and issues.\nHighly motivated and able to work with minimal guidance, independently and as a team participant.\nOutstanding verbal and written communications skills with the ability to communicate clearly to all levels of an organization.\nAbility to work in a high paced environment independently and with cross functional groups.\nKnowledge of ACA, Medicare, Medicaid, MCO, TPA business requirements preferred.\nExperience with healthcare encounters, enrollment and pharmacy data preferred.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

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QUALIFICATIONS

\n\nEDUCATION - Bachelor's or 4 years of work experience above the minimum qualification\nEXPERIENCE - 3 Years of Experience\n\n3 years of Medical Claim Experience in claim processing and/or insurance billing\n2 years of Medical Claim Encounter Experience\nHealthcare billing \nTexas Medicaid guidelines/billing knowledge\nExpert in Excel (Pivot tables, importing data, sorting data, etc.)\nExpert with SQL programming \n\n\n