Enrollment Encounter Data Analyst

This position is responsible for compiling, analyzing, trending, tracking, and interpreting all Medicare-Medicaid Plan and Medicaid enrollment activities and is responsible for researching, interpreting, analyzing, and correcting all pended and rejected Medicaid and Medicare encounters including complex encounter issues in accordance with contract guidelines.

1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.

2. Ensures data integrity and accuracy in all enrollment and encounter processes through analysis of potential system issues with the 834 and 837 transactions. Serves as the subject matter expert and liaison for 834 audit and daily file reconciliations with the Michigan Department of Health & Human Services (MDHHS); participates in the enrollment and encounter workgroup meetings as necessary.

3. Submits Medicaid service requests through the Community Health Automated Medicaid Processing System (CHAMPS) to MDHHS regarding enrollment and/or payment issue discrepancies as well as MI Health Link (MHL) discrepancies and immediate access of care issues between the Center for Medicare and Medicaid Services (CMS) and MDHHS.

4. Oversees and works closely with the encounter vendor and internal staff to ensure the accurate and timely submissions of encounter data and analyzes and resolves encounter pends/rejects in the encounter system.

5. Responsible for the day-to-day resolution of verbal and written inquiries regarding enrollment, encounter, and newborn activities from other staff, providers, and members, and works closely with claims staff assessing and confirming that all incoming enrollment, provider, and claims data is accurate and complete.

6. Verifies Maternity Case Rate (MCR) payments have been received for all qualifying births and that newborns are enrolled with UPHP appropriately.

7. Serves as Domain Administrator for CHAMPS.

8. Processes member  and new member packets. Validates health plan material mailings by the print vendor, verifies vendor invoices, and ensures print vendor compliance with our contract.

9. Works closely with the Data Infrastructure (DI) team to test and validate 834 enrollment file and 837 encounter file change to accommodate MDHHS and/or CMS requirements.

10. Acts as liaison to external vendors regarding enrollment and encounter data when outreach is needed.

11. Serves as enrollment and encounter data subject matter expert for audits and compliance reviews.

12. Works with the Risk Adjustment Analyst & Coding Compliance Auditor to interpret and correct errors within the risk adjustment and encounter data processing systems.

13. Participates in the Revenue Reconciliation process including assisting the Finance Department with identifying and resolving capitation rate payment issues.

14. Works closely with the Compliance Department and external vendors to identify and validate accurate claim encounter activity for Program Integrity submissions to MDHHS.

15. Maintains written documentation of all activities and revises procedures and policies to increase efficiency and accommodate any changes.

16. Applies for Wisconsin Medicaid on behalf of TPA Client, WI Department of Corrections, incarcerated individuals, while they are inpatient status.

17. Maintains confidentiality of client data.

18. Performs other related duties as assigned or requested.

Associate degree in health information processing, computer information…