Health Plan Services (HPS)
Senior Medicare EDI Encounters (EDPS/RAPS) Analyst
Chicago, IL, United States
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Senior Medicare Business Analyst – Encounters

 

What You’ll Be Doing:

 

Medicare Encounter Operations, Health Plan Services (HPS) is responsible for managing day to day operations Medicare encounters on behalf of Evolent clients.  Operational areas of responsibility include encounter data management, submissions, reject remediation, and client/internal reporting as well as coordination/reconciliation with state regulatory bodies.

 

This individual must be experienced in managing day to day encounter operations around state Medicare encounter submissions.  This position will report to the Director or Associate Director of Encounter Operations and is located in the Chicago, IL area.

Mandatory –

  • Experience working in Client facing engagements and act as key Stakeholder in the TPA functions related to Encounter Management and Reporting.
  • Experience working among Payer & Provider Community to facilitate implementation of improvements of State/Federal Managed Care Programs or similar Care Coordination programs.
  • Ability to manage and track the implementation of tasks, operational improvements and enhancements in order to meet Client specific goals.
  • Experience in Executive level clear and concise project status and data management reporting.
  • Experience working in vertically aligned cross functional teams to identify interdependencies to support program implementation and enhancements.
  • Experience with mentoring and training other Business Analyst to support ongoing operations.

Responsibilities -

  • Responsible for timely, complete, and accurate encounter data submissions that meet or exceed state and/or federal requirements
  • Work with HPS Business Operations and IT Engineering to implement a strategic approach to encounter data management encompassing internal and external data sources, technical infrastructure, process automation, and issue/reject remediation workflow
  • Identify, develop and drive initiatives to increase the Encounter Operations function regulatory compliance levels, productivity/efficiency, process consistency, and long-term scalability
  • Oversee the on-boarding of new encounter clients to include requirements gathering/documentation and coordination with HPS Implementation, Business Operations, and/or HPS Engineering teams (as required)
  • Develop and execute action plans to respond to new encounter regulatory requirements
  • Efficiently and effectively manage internal and external escalations
  • Data management and analysis reporting utilizing SQL, MicroStrategy and similar reporting tools
  • Medicare Encounter management and processing utilizing Encounter Management platform
  • Data movement and transformation utilizing Move-IT and SSIS and SFTP protocols, processes and tools

 

The Experience You’ll Need (Required):

  • Understanding and experience with standard claim Electronic Data Interchange file formats and protocols such as 837I, 835, 277, 999 among others
  • Bachelor’s degree in Healthcare Management, Computer Science or another technology/business field of study
  • Hands-on experience with EDI X12 837 transaction set in the context of CMS EDPS/RAPS data submission
  • Dissecting CMS MAO-001 and MAO-002 reports and taking corrective actions to improve encounter throughout and quality
  • Experience Monitoring, troubleshooting, and correcting EDI transactions in Encounter Management Platform.
  • Excellent analytical and problem-solving skills in Healthcare data operations, specifically with Claims and Encounters data.
  • Experience working with TPA and establishing Third Party Vendors EDI contractors – Encounter Data submission.
  • Experience working with Request Management tools like HP QC, ReqPro, JIRA, or similar industry standard tools.
  • Ability to perform typical business analyst duties such as requirements gathering, solution design, testing to meet business needs.
  • End to End knowledge of Healthcare Payer data operations.
  • Experience working in Government Programs – Medicare/Medicare.
  • Strong SQL Server Management Studio experience or similar products.
  • 5-7 yrs experience in leading Medicare encounter operations, Illinois or Florida Medicare market experience a plus
  • Experience in healthcare payer systems required and knowledge of Medicare products and programs preferred



Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

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