Job Description :
Job Description:
Claims Review Analyst
Job Overview
This position would monitor all incoming and outgoing encounters/claims to ensure accuracy and troubleshoot any failures or others issues.
This person will work closely with encounter team and IT staff.
Our Process
Our Company pay claims to Medicaid members on medical, dental and pharmacy claims. Clean and adjudicated claims call encounters. Then we submit these encounters to the State, so they can calculate the rate to reimburse us. Most of our encounters data is coming from vendors (third-party administrators) and, some, from our internal system. These vendors send us their files and we, in-turn, submit to the State’s system. All these processes are automated; some files involved EDI department to convert to certain formats that fit the State’s requirement before sending on.
Our Needs
The State feels that encounters in their Data Warehouse don’t match with our Data Warehouse. Audit will perform frequently to reconcile encounters between data warehouses. There is a need for someone to be able to extract data, analyze, evaluate the root cause, and summarize finding.
Our data, however, are in various tables. I need someone who could write a query (SQL), to link these tables and extract data; and manipulate it in various tools to arrive essential information for evaluation.
Sometimes there are issues with encounter transmitting issues, so I need this person have a good understanding of FTP for file transferring troubleshooting.
In addition, there are times the State implements new changes on how they want to submit encounter data. This requires involvement with IT folks, to provide assistance on coding/testing new changes. This position requires skill to facilitate staff members in different departments and able to communicate with IT folks, as well.
Requirements
Someone with experience developing PLSQL procedures in Oracle/SQL Server
Someone excellent with formula writing in Excel
Someone with excellent analytical and reporting skills
Experience:
2 years of experience preferred
Writing SQL codes
Excel – Intermediate to Advance
Access, FTP, and Tableau reporting is a plus but not essential
Skills:
Attention to detail
Excellent Communication - need to be able to explain their reports
Work well in a team environment and flexible on schedule