Job Details

The Encounter Analyst I reviews 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 fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required.

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

$20.32 - $25.91/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 Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.