Medicare Encounter Data Analyst — Regulatory & QA

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Doral, FL, US

11 days ago Requisition

Salary: $90,000.00 Annually

POSITION SUMMARY

The EDI senior analyst is responsible for monitoring, analyzing, validating, and reconciling Encounter transactions supporting operations and regulatory reporting.

This position serves as a key liaison between Claims, Risk Adjustment, Enrollment, IT, Finance, and compliance teams to ensure that Encounter data received is complete, accurate, timely, and appropriately reflected in downstream reporting.

The analyst will trace Encounters from their original source through systems and ultimately to applicable regulatory submissions, including CMS and, where applicable, AHCA requirements.

The position will investigate discrepancies, identify root causes, document findings and coordinate corrective actions.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Monitor incoming and outgoing encounter transactions.
• Review EDI files and transactions for completeness, accuracy, errors, and missing information
• Analyze EDI transaction data through the organization’s systems to determine how the information was processed.
• Reconcile EDI data against membership, claims, encounters, providers, and other source systems
• Establish and maintain data lineage between encounter sources and CMS and other regulatory entities
• Evaluate CMS submission files and reports to identify discrepancies, rejections, errors, and data inconsistencies.
• Track EDI-related issues through resolution and maintain appropriate documentation and audit trails
• Work with appropriate teams to resolve issues
• Develop and maintain reconciliation reports, exception reports, dashboards, and tracking logs.
• Identify recurrent data quality issues and recommend process or systems improvements.
• Support regulatory audits
• Maintain knowledge of regulatory data requirements, specifications, and submission process.
• Ensure issues are escalated properly and resolved.

QUALIFICATIONS AND EDUCATION

• Bachelor’s degree in information technology, Health Information Technology, Business Analytics, Computer Science, Healthcare administration or related field.
• 2+ years of experience working with EDI, Healthcare data, encounters, and claims.
• Experience working with Medicare Advantage data, CMS reporting, and requirements.
• Experience with data reconciliations, validation, and root-cause analysis.
• Ability to trace data across multiple systems.
• Strong excel/data analysis skills
• Strong documentation and analysis skills.

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing, and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the…