The Encounter Analyst I review and monitors adjudicated claims for file submission and upstream processing and communicates with provider agencies and internal departments regarding claims submission, denial management, and system updates. The position tracks trends and patterns to identify irregularities in the ACS system and works with claims analyst to communicate claims issues. The position has shared responsibility for ensuring contract service level agreements are met.
This position is full-time remote. The selected candidate must reside in North Carolina and be willing to travel onsite at the Home office (Morrisville, NC) for trainings at minimum of 2 weeks.
Responsibilities & Duties
Research and Resolve Encounter Denials
Research upstream encounter denials
Determine if claim processed appropriately in ACS
Rebill encounter denial when appropriate
Research State initiated encounter recoupments
Ensure Service Level Agreement (SLA) Maintenance
SLAs: Accuracy, Timeliness, and Reconciliation
Accuracy: Review and be aware of number of denied encounters weekly.
Timeliness: Research and resolve 98% of encounter denials within 30 days.
Reconciliation: Assist in researching discrepancies
Manage Encounter Denials and Recoupments
Utilize the A/R system to manage encounter denials and recoupments
Document current status of denials and recoupments
Process and Reconcile Claims
Ensure appropriate coordination of benefits has occurred utilizing billing and payment policies and procedures, review & analyze claims adjudications to identify system issue and provider errors
Maintain knowledge of current adjudication edits
Provide Feedback on Process Improvement
Provide information and feedback to the system team to support development of system enhancements in a structured manner aimed to eliminate system settings and or processes that contribute to poor results
Maintain processes that are consistent with and compliant to CMS, state, federal and best practice standards, regulations and guidelines
Communicate and Collaborate with Internal and External Stakeholders
Communicate and conduct liaison work across multiple departments to resolve claims denials/issues
Communicate with DMH/DHB when appropriate to resolve complex encounter denials/issues
Demonstrate professional and timely communication
Minimum Requirements
Education & Experience
Graduation from high school or equivalent and (4) four years of experience processing healthcare claims
Experience with Medicaid and IPRS preferred
Knowledge, Skills, & Abilities
High level knowledge of healthcare services and systems
Knowledge of complex claim denials and sources for correction
Knowledge of Medicaid and State funding rules
Knowledge of laws, legal codes, precedents, government regulations, and MCO policies and procedures
Microsoft Office (Excel, Word, Outlook) skills
Professional written and oral communication for sharing technical information
Ability to independently identify necessary tasks and initiate action
Ability to independently find answers to complex issues
Ability to analyze large quantities of data
Ability to solicit cooperation from persons and departments throughout the organization
Ability to work independently and as part of a team
Ability to demonstrate professional conduct in all situations
Ability to take initiative and lead others
Salary Range
$19.73 - $25.16/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, 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
