Overview
Skills
Job Details
Role: Encounters Systems Analyst)
Location: 100% Remote (United States)
Duration: 6 12 Months
Summary:
The Encounters Systems Analyst will be responsible for compiling, analyzing, and reporting healthcare encounter data, ensuring compliance with CMS and state requirements. This role requires strong experience in healthcare data, claims encounters, and regulatory reporting. The ideal candidate will have a deep understanding of claims systems, data analysis, and encounter data processes.
Key Responsibilities:
Compile and analyze Encounter data; assess financial and clinical impact of business process changes.
Provide analytical support and leadership for Claims Encounter Regulatory Data projects.
Review Encounter rejections and resolve complex data or process issues.
Serve as a Claims Encounter Subject Matter Expert (SME) for CMS, state agencies, and internal teams (IT, Claims, Enrollment, etc.).
Design, test, and deliver supporting business processes.
Lead claims data processes ensuring accuracy and compliance with CMS/state agencies.
Support vendors and manage SLAs, regulatory requirements, and contractual metrics.
Lead automation initiatives and improve regulatory reporting processes.
Prepare and monitor management and oversight metrics/reports.
Develop and guide user stories for sprint planning.
Ensure claims payment, adjudication, and state encounter processes remain compliant.
Required Skills & Competencies:
Strong experience in healthcare/insurance industry (mandatory).
Proficiency with SQL Server (2016 or newer) and relational databases (SQL Server, Oracle, etc.).
Expertise in SQL querying, data analysis, and trend identification.
Knowledge of Claims Encounters, claims operations, and managed care processes.
Understanding of coding and billing (CPT, ICD-9, ICD-10, HCPCS).
Experience with 837O (State/CMS submissions) and 835 files preferred.
Familiarity with Edifecs preferred.
Knowledge of claims IT and analytic processes/systems.
Strong communication, time management, and critical thinking skills.
Ability to work independently and collaboratively across departments.