Business Encounter Data Analyst

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary The Business Encounter Data Analyst is responsible for compiling and analyzing encounter data and understanding the claim impact of changes and decision to the business process to ensure that CMS and State Service Level Agreements (SLAs) are achieved. This individual will support the encounter data lifecycle process working closely with business and technical resources as well as document and illustrate business requirements, processes, and deficiencies across the organization, our vendors, and our regulators. Our Investment in You Full‑time remote work Competitive salaries Excellent benefits Key Functions/Responsibilities Understand the claims encounter data requirements in detail to ensure claims data is complete, accurate, and timely. Responsible for reviewing encounter rejections and providing resolution of minor to complex data/system issues or processes. Responsible for the development and maintenance of supporting business processes and workflows. Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies. Provide critical analysis of functional performance, and make recommendations for enhancements, and process improvements. Build, sustain and leverage relationships to constantly allow for continuous improvement of the encounter data business process. Provide encounter data support to vendors and ensure understanding of regulatory encounter requirements. Participate in claims encounter initiatives such as working with IT and others internal departments to automate claims encounters functions. Understanding of how claims payment methodologies, adjudication processing and CMS and State encounter regulations interrelate to maintain compliant encounter reconciliation processes and SLA’s. Stay current with the needs and operations of the regulatory deliverables. Interact with business stakeholders, internal and external as appropriate, to understand new business requirements and enhancement requests. Provide business encounter subject matter expertise for internal departments and both CMS and State agencies. Performance for timely and accurate reviews must meet or exceed internal, CMS, and State SLA requirements. Other duties as assigned Supervision Exercised None Supervision Received Indirect supervision is received weekly Qualifications Education Required Bachelor’s Degree in a related field or the equivalent combination of training and experience. Education Preferred AHIMA or other nationally recognized Coding/Billing Certification. Experience Required 5 or more years experience in a fast paced, managed healthcare environment. 5 or more years experience with encounter data operations, claims processing, and/or provider billing. 3 or more years of claim coding and billing processes, including CPT, ICD‑10 and HCPCS coding. Advanced knowledge of HIPAA regulations and 837 EDI standards. Experience working with Medicaid, Medicare or commercial encounter, coding and/or regulatory guidelines. Experience Preferred/Desirable Edifecs encounter data software. Cognizant Facets claim adjudication system. Experience with industry standard payment rules and methods. Required Licensure, Certification or Conditions of Employment Successful completion of pre‑employment background check Competencies, Skills, and Attributes Effective collaborative and proven process improvement skills. Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation. A strong working knowledge of Microsoft Office products. Independent thinker and problem solver with an analytical mind and the ability to solve complex data and workflow issues. Detail oriented. Compensation Range $64,000 – $93,000 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market‑competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Note This range is based on Boston‑area data, and is subject to modification based on geographic location. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high‑quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. EEO Statement Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees. #J-18808-Ljbffr