Candidates hired for remote positions must reside in Oregon or Washington.

Job Summary

The Medicare Encounter Data Analyst leads the process for the end-to-end Encounter Data Processing System (EDPS) data flow and works within CMS guidelines for acceptable data submission. Using SQL and SAS programs, monitor submissions of core claims and supplemental data and reconcile against CMS response files. This position influences leadership decision making and provides recommendations regarding potential improvements to Encounter Data submissions.

Essential Responsibilities

• Ensure accuracy and completeness of the data submissions to CMS.
• Design/develop encounter data controls and internal audit processes with internal signoffs.
• Provide dashboards, reports, and analysis specific to the complete and accurate submission of encounter data to CMS.
• Monitor and track Medicare encounter data throughout the entire submission process, ensuring integrity through ongoing reconciliation of EDI, claims, supplemental data, and outgoing 837 file creation to prevent data loss.
• Identify root cause of data loss and encounter rejections; research return codes and coordinate with IS, claims, enrollment and provider data to enable complete and accurate encounter submissions.
• Work cross-functionally to interpret, verify, test and correct errors within the encounter data processing system.
• Maintain business rules and policies and procedures for Medicare encounter data submissions; lead the updating of business rules in response to regulatory changes.
• Lead and manage the standardization and automation of encounter data table creation and response file loading from CMS.
• Compile reports for other departments and regulatory agencies.
• Use statistical software, including SAS and SQL, to retrieve, edit and tabulate data from various databases and files.
• Participate in cross-departmental encounter data workgroup meetings.
• Analyze data trends and creates documentation supporting all reports.
• Advise on and guides process improvements that will optimize the accuracy and completeness of Medicare encounter data submissions.
• Work with outside vendors as needed.
• Advise internal customers regarding the availability and utility of data elements for reporting and data set requests, as well as the timing and frequency of reporting and data refresh.

Organizational Responsibilities

• Perform work in alignment with the organization's mission, vision and values.
• Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization's strategic goals.
• Adhere to the organization's policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 5 years' experience reporting, analyzing, interpreting, and presenting data; experience analyzing large data files and performing file reconciliations.
• Minimum 3 years' healthcare, claims, data management, EDI experience

Preferred

• Experience with Medicare Advantage risk adjustment and payment methodologies

Knowledge, Skills and Abilities Required

Knowledge

• Advanced knowledge of statistical software packages, such as SAS
• Knowledge of risk adjustment methodology and Medicare encounter data
• Knowledge of Medicare programs
• Knowledge of medical and/or pharmacy claims
• Knowledge of CPT, HCPCS, ICD10 coding; revenue codes; DRG, UB04, and CMS 1500 claims submission and electronic claims submissions; CMS policy
• Knowledge of user-oriented programming languages including SQL

Skills and Abilities

• Intermediate skills with spreadsheets and word processing applications

• Excellent written and verbal communication skills
• Ability to independently gather, interpret and analyze data
• Ability to extract data from databases using such software tools
• Ability to design and run intermediate to complex queries and reports
• Ability to manipulate and analyze statistical data
• Ability to prepare narrative and statistical reports
• Ability to identify trends, problems, and opportunities for improvement
• Ability to effectively convey concepts and influence leadership decision making
• Ability to manage multiple tasks

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see for at least 6 hours/day
• Ability to read, hear, speak clearly and perform repetitive finger and wrist movement for at least 3-6 hours/day

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.

#Li-Remote

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Visa sponsorship is not available at this time.