Encounter Data Coordinator

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

This position is responsible for all aspects of Oregon Health Authority (OHA) encounter data submission administration including overseeing delegated vendor's encounter data submission process. This position is also responsible for all aspects of the Centers for Medicare and Medicaid Services (CMS) encounter data and risk adjustment submission administration. Additionally, this position is responsible for keeping management informed of progress and issues related to all aspects of encounter data.

• Coordinate and evaluate the encounter data and risk adjustment submission programs.
• Recommend and implement encounter data and risk adjustment policies and procedures.
• Maintain detailed standard operating procedures for all essential functions of the position.
• Identify and resolve issues preventing complete and accurate encounter and risk adjustment submissions through analyzing CMS submission errors and OHA pended encounters and working to minimize.
• Work closely with Claims Department to ensure claims policies correspond to OHA's and CMS encounter data submission requirements.

• Work closely with System Coordinators and Provider Data staff to ensure CareOregon claims system configuration corresponds to OHA and CMS requirements.
• Work closely with CareOregon software developers to ensure compliance with 837 and RAPS file creation, and to assist in maintaining accurate encounter data submission logic in keeping with current regulatory requirements.
• Work closely with software developers to test and maintain COWA application for managing OHA pended encounters and CMS encounter errors.

• Analyze monthly/weekly reports from OHA and CMS.
• Work collaboratively with other departments and management to ensure ongoing encounter submissions are effective, progressive, and meet organizational needs.
• Identify opportunities and initiate collaborative efforts for process improvement.
• Provide reports and trend analysis of encounter and risk adjustment data.
• Create reports using QNXT reporting services and CareOregon Web Applications (COWA).
• Attend annual CMS risk adjustment and other appropriate CMS meetings.
• Communicate within the team when new encounter data issues arise and collaborate on how to address.
• Attend monthly OHA All Plan System Technical meetings.
• Monitor delegated vendor's encounter data process and submissions to ensure compliance with OHA requirements.

• Act as a liaison and first point of contact with OHA and delegated vendor regarding encounter data progress or issues.
• Coordinate weekly encounter submission paperwork, working closely with the authorized signers for each CCO and on behalf of Health Share.
• Parse out weekly and monthly CCO encounter data reports and securely share data with delegated vendors.
• Coordinate Trading Partner Agreements (TPAs), working closely with delegated vendors and OHA to maintain.
• Track encounters eligible for Maternity Kicker Payment (MKP) from OHA are ensure reimbursement.

• Handle all aspects of encounter data reconciliation on behalf of all delegated vendor submitters and Health Share, including: addressing ad hoc questions and issues; providing support on provider enrollment; reconciling reported submitted encounters against the Claim Count Verification (CCV) report provided weekly by OHA; processing and communicating on the Deceased Client Report, the Unencountered Claims report; and adjusting or voiding encounters on MMIS as needed.

• Perform work in alignment with the organization's mission, vision and values.
• Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization's strategic goals.
• Adhere to the organization's policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 3 years' experience in health insurance claims administration

Knowledge

• Advanced knowledge of CPT, ICD-10, HCPCS and revenue coding
• Working knowledge of CMS encounter data and Risk Adjustment submission and compliance requirements
• Working knowledge of OHA OARs, CMS CFRs, and encounter data systems, including submission and compliance requirements, filtering and resolving errors
• Advanced knowledge of CareOregon's claims policies and procedures
• Basic understanding of State/Federal laws and other regulatory agency requirements that relate to the medical health insurance industry or Medicaid/Medicare industry

Skills and Abilities

• Excellent written and verbal communication skills
• Excellent customer service and problem-solving skills
• Strong Excel skills
• Multidisciplinary collaborative skills
• Ability to analyze data
• Ability to prepare narrative reports
• Ability to organize, prioritize, and manage multiple tasks
• Ability to proactively work to build and improve the encounter data and risk adjustment processes
• Ability to participate fully and constructively in meetings
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.

#Li-Hybrid

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.