JOB PURPOSE: The Director of Encounter and Data Analytics is responsible to lead the end-to-end accurate and timely claims payment processes, including managing TPA’s performance, ensuring the integrity of payment configuration, and processing of claims appeals. This position will work collaboratively with CenterLight key stakeholders as well as external providers and vendors to ensure the accurate and timely payment of claims. The role will provide leadership and strategic vision in streamlining the medical payment processes to reduce cost, improve outcomes while adhering to CMS and NYS DOH requirements to prevent fraud, waste, and abuse (FWA). This position requires working knowledge of health care policy and payment methodologies along with strong organizational and analytical skills. JOB RESPONSIBILITIES: Claims payment integrity: + Lead and deliver accurate and timely claims payment integrity analysis, including vendor oversight, to ensure compliance with federal and state guidelines and meets CMS, NYS DOH and provider contract requirements. + Perform accurate and timely claims payment integrity, including root cause analysis, over/under payment, reconciliation to provider contracts/agreements and Medicare/Medicaid fee schedule. + Develop analytics of payment trends that will provide accurate and actionable insights for configuration and edit changes. This includes but is not limited to DRG, APC, FFS, capitation, and VBP. + Ensure capitated payments are processed according to the contracts and troubleshoot configuration, benefit, and coding issues. + Work with Finance, Compliance, Provider Relations, Care Delivery, and Business Development to ensure accurate claim outcomes and accurate and actionable insight for key decision-makers. + Address any issues that raised and escalate as appropriate. Claims delegation and operations: + Manage day-today claim adjudication processing, including monitoring of pending claims, appeals, recoupments, and pricing, to ensure the accuracy of member benefit, fee schedule, and edit rule configurations. + Coordinate with Finance regarding check runs and provider payments, including refunds, overpayments, and underpayments. Review for potential issues, investigate and propose solutions to leadership. + Ensure claims processing is in compliance with regulatory agencies and organizational expectations, including CenterLight policy, NYS Prompt Pay Law, NYSDOH, NYSDFS, CMS, and Contractual requirements. + Monitor claims inquiry inventory, non-auto adjudication claims rates, cycle time for review, final resolution, and work quality to assure conformity with corporate objectives and department goals. + Maintain organization of workflows related to TPA and internal operations impacting claim adjudication. + Work closely with TPA to ensure vendors are meeting the SLA’s on timeliness and accuracy. + Track and monitor all open tickets with TPA and address issues in closing out any tickets. + Review current business processes and recommend modifications to streamline workflow. Claims appeals and audit: + Provide oversight in the end-to-end claim appeals process. + Work with the team and Quality to streamline claim appeals process to improve team daily productivity and meeting regulatory deadlines. + Develop management review process to improve accuracy on determination. + Conduct claims sample audits to ensure claims payment and configuration integrity. + Assist in the collection and preparation of data for applicable state, federal, and internal inquiries. + Perform ad-hoc analysis to support organization strategic initiatives. + Other duties as assigned. Management standards: + Policies and Procedures: (1) Create Policies and Procedures needed, (2) Monitor Compliance, (3) Ensure all employees are aware of the policies, (4) Review them annually, (5) Discuss and obtain final approval of new or revised policies with the P&P committee annually. + Manage, teach, and mentor staff. Responsible for hiring, appraising, developing, and whenever applicable, disciplining staff for performance issues. + Collect and analyze the projects business requirements and transition knowledge to the team and other key stakeholders. + Validate data quality, ensure business reporting needs are fulfilled, and processes are documented. + Works with leadership to identify, define and utilize standard tools and analytical approaches + Responsibilities for maintaining vendor relations (TPAs, payment integrity vendors), providing analytics support during contracts negotiations and renewals. + Ensure a high level of customer service for internal and external customers. + Keep abreast with any updates to claims payment configuration requirements from both governmental agencies (NYS DOH and CMS), including attending recurring work group meetings with both agencies. + Support and promotion of automation and reporting tools adaption to streamline reports and analytics operations and delivery. Schedule: 8:30AM – 5:30PM Weekly Hours: 40 QUALIFICATIONS: Education: Bachelor’s degree in business, Finance, Healthcare, Informatics, or related field required. Experience: + Minimum of 5 years of experience in medical economics and claims operations in managed care/ government programs (Medicaid and Medicare) setting. + 3 years of staff management experience. + Industry level knowledge of state specific Medicaid and Medicare rules, regulations, and processes. + Must have advanced Excel, Access, Visio and PowerPoint skills. + Must have advance big data analytics and reporting tool: SAS, SQL, Tableau skills. + Excellent written and verbal communication skills are essential as this position will be interacting with various departments across the organization and external parties, including government agencies. + Experience building financial models and big data analytics using medical claims and CMS and NY DOH files as data source. + Highly organized with an attention to details. The ability to adapt to and lead change in a business environment is also critical. + Must be an independent and creative thinker. + Experience working effectively and influencing others on cross-functional teams. + Must be able to manage and deal with conflict and stressful situations in a calm, reasonable and composed manner. + Excellent leadership, communication, and interpersonal skills. Physical Requirements Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to: + Standing – Duration of up to 6 hours a day. + Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods. + Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc. + Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job. + Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas. + Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.) + Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy. + Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. + Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job. Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company. We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Salary Range (Min-Max):$150,000.00 - $160,000.00