Job Description

As a healthcare organization dedicated to providing quality services to the Central Coast community, our client is seeking a highly motivated individual to join their team. The ideal candidate will be committed to the mission of improving the health and well-being of members of the community and will bring a combination of skills, experience, and passion to the role.

The Medicare Encounter Data Analyst provides data collection, analytical, reporting, and project management support to the Claims Operations team related to the processing, correction, and transmission of highly accurate encounter data. This role validates and analyzes reports and logs related to encounter transactions to ensure compliance, accuracy, completeness, timeliness, and continuous process improvement.

Key Responsibilities:

• Ensure adherence to regulatory and internal guidelines in conjunction with company policies and procedures related to encounter reporting
• Perform data analysis on submitted encounter data files and produce regular reports of findings
• Measure encounter data accuracy, submission, and correction timeliness against contractual obligations; recommend procedural changes as needed
• Monitor and analyze encounter data reporting for accuracy and compliance
• Maintain in-depth knowledge of encounter data reporting requirements and regulations
• Analyze and interpret encounter data to identify errors and develop solutions to mitigate them
• Review and analyze encounter submission regulatory guidelines to ensure compliance with system editing logic
• Partner with IT on encounter data issues, process development, and system changes to improve encounter management
• Collaborate with other departments, vendors, and the provider community on ongoing encounter data process improvement projects
• Develop system change forms (SCFs) to improve data quality and reduce rejections
• Oversee outsourced vendor encounter data processing, ensuring contractual obligations are met and corrective actions implemented when necessary
• Manage downstream delegate (VTS) encounter data, including error review, correction, and resubmission to CMS
• Track and maintain encounter-related project reporting for internal teams and external vendors
• Review errors received from CMS, make corrections, and develop preventative processes for future accuracy
• Develop and present encounter data reports for internal committees and vendor oversight meetings
• Support encounter data management for specialized programs (ECM/CS)
• Participate in internal and external meetings and maintain compliance with all organizational policies and procedures

Qualifications:

• Strong knowledge of the Medicare D-SNP program and dual-eligible encounter processing (Medi-Cal and Medicare D-SNP)
• Hands-on experience with Cognizant EDM application systems
• Bachelor’s degree in Healthcare Administration, Business Administration, or a related field (or equivalent experience)
• 2–3 years of experience in data analysis within a managed healthcare environment; claims experience highly desirable
• Proficiency in MS Office Suite, with intermediate to advanced Excel skills
• Experience with healthcare system configuration, data analysis, and familiarity with database systems
• Understanding of primary coding systems (CPT/HCPCS, ICD-10, NDC)
• Strong analytical and problem-solving skills
• Excellent communication and collaboration abilities
• Experience with QNXT system preferred
• Knowledge of Medicare claims processing in QNXT preferred
• Familiarity with CMS and Medi-Cal program regulations and reporting requirements preferred
• SQL experience preferred

Compensation:

• Salary Range: $76,466 – $93,670 – $110,875

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