The Medicaid Encounters Lead is responsible for monitoring and oversight of the end-to-end encounter management workflow for Humana Healthy Horizons in Florida. In collaboration with Encounters, Finance and Operations teams, the Medicaid Encounters Lead analyzes and reconciles complex encounter inbound/outbound process issues, using data from internal and external sources to identify process improvements and provide insight to decision-makers. In addition, the Medicaid Encounters Lead role ensures internal claims processing logic aligns to state encounter processing guidelines to minimize encounter rejections. This role will also be responsible for guiding and overseeing encounters reconciliation between providers and Humana. The ability to clearly articulate issues and solutions to team members, management, and external entities is crucial to the success of this Medicaid Encounters Lead role.
- Responsible for documenting, monitoring and analyzing the end-to-end encounter life cycle, both inbound and outbound.
- Identify and interpret encounter data, submission requirements and performance metrics per regulatory and health plan guidelines.
- Research and document all encounter errors in systems/databases; perform encounter data reconciliation and statistical and trend analysis.
- Oversee the reconciliation processes for delegated vendors and risk providers to ensure the Plan has received all submitted encounters.
- Perform root cause analysis of claims/encounters processing and submission issues; communicate with management and provide recommendations.
- Collaborate with other departments on designing and implementing system/business process adjustments as needed to meet encounter data processing and submission goals.
- Communicate with and provide clear documentation to other departments on issues causing encounter pends/denials and potential solutions.
- Develop encounter-related reports (e.g. exception reports, root cause analysis outcome reports, etc.) and provide to other departments for error resolution, follow-up and performance monitoring.
- Participate in resolving encounter data and process issues.
- Review and research inquiries from regulatory bodies and/or health plans related to submission data, including score cards from health plans.
- Bachelor’s degree in a healthcare field or equivalent experience.
- 5+ years of experience in managed healthcare analysis, preferably as a Business Analyst or similar role.
- 2+ years of project leadership experience.
- Advanced experience working with big and complex data sets within large organizations.
- Advanced in SQL, SAS, and other data systems.
- Comprehensive knowledge of all Microsoft Office applications, including Word, PowerPoint, Outlook, and Excel.
- Experience with user acceptance testing, training, writing business requirements, and mapping business processes.
- Demonstrated experience with problem solving and process improvements; ability to give direction and make sound business decisions.
- Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.
- Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.
- For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
- If progressed to offer, you will be required to: Provide proof of full vaccination OR Commit to weekly testing, following all CDC protocols, OR Provide documentation for a medical or religious exemption consideration. This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.
- Experience with Florida Medicaid encounters.
- Experience with ANSI X12 EDI standards for healthcare.
- Workstyle: Remote or Hybrid Office. The workstyle will be Hybrid Office if you live in a commutable distance to the Humana Healthy Horizons office location in Tampa, FL. Hybrid office is defined as working 3 – 4days/week in the office location and 1 – 2 days/week remote. Leadership will determine the frequency.
- Work Hours: Eastern Standard Time.
- Direct Reports: up to 2 associates
- Travel: up to 10%
Scheduled Weekly Hours