Senior Claims Operations Analyst (Encounters)

Essential Functions

• Serve as the technical subject matter expert for Encounter Operations by researching, analyzing, and resolving complex encounter, claims, reimbursement, and operational issues requiring advanced analytical judgment.
• Monitor encounter production, submission, acceptance, rejection, timeliness, and data quality by analyzing operational metrics, regulatory reports, and encounter performance indicators to ensure regulatory compliance and accurate reporting.
• Perform advanced encounter validation, reconciliation, and analysis between adjudicated claims, encounter files, regulatory acknowledgments, and source data to ensure completeness, accuracy, and data integrity.
• Lead root cause analysis of encounter processing issues by investigating defects related to claims adjudication, configuration, provider data, reimbursement methodologies, transaction mapping, system functionality, and operational workflows.
• Lead or support business requirements development, configuration validation, User Acceptance Testing (UAT), production implementation, and post-production monitoring for encounter-related system enhancements, regulatory changes, and operational improvements.
• Collaborate with Claims Operations, Information Technology, Configuration, delegated entities, vendors, providers, and regulatory agencies to resolve complex encounter and operational issues while improving end-to-end business processes.
• Develop, review, and maintain encounter operational procedures, workflows, reconciliation processes, business requirements, testing documentation, job aids, and operational standards.
• Analyze encounter quality, operational performance, compliance, financial impacts, and service levels by reviewing encounter data, claims, operational reports, and related information to identify trends, risks, and opportunities for continuous improvement.
• Support oversight of delegated entities and business partners by monitoring encounter submission performance, validating data quality, evaluating operational effectiveness, and coordinating corrective actions as needed.
• Prepare complex analyses, executive summaries, dashboards, reports, presentations, and recommendations supporting regulatory reporting, audits, compliance activities, operational decision-making, and strategic initiatives.
• Maintain advanced knowledge of encounter reporting requirements, claims adjudication, reimbursement methodologies, healthcare transaction standards, Medi-Cal and Medicare regulations, provider contracts, and industry best practices while serving as a resource to leadership and staff.
• Lead or participate in cross-functional operational initiatives and perform other duties as assigned to improve encounter quality, regulatory compliance, operational efficiency, and organizational performance.

Minimum Qualifications

Education: High School Graduate or General Education Degree (GED)

Knowledge of:

• Medi-Cal, Medicare, and D-SNP programs, including managed care operations, eligibility, benefits, and regulatory requirements
• Healthcare claims processing, medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms
• Encounter reporting requirements, encounter life cycle, claims adjudication principles, provider reimbursement methodologies, and health plan operational workflows
• Encounter transaction standards, encounter validation, reconciliation processes, regulatory edits, submission acknowledgments, and error resolution concepts
• State and federal healthcare regulations applicable to managed care organizations, including DHCS, CMS, and DMHC requirements governing claims and encounter reporting
• Provider contracting concepts, Division of Financial Responsibility (DOFR), reimbursement methodologies, delegated operations, and health plan contractual obligations
• Root cause analysis, business process improvement, system implementation concepts, User Acceptance Testing (UAT), and operational quality management
• Claims adjudication systems, encounter processing systems, reporting tools, and Microsoft Office applications, including advanced Excel

Preferred Qualifications

• Five (5) years of progressively responsible experience in encounter operations, claims operations, managed care, healthcare reimbursement, or a related healthcare operational environment
• Experience with Medi-Cal/Medicaid managed care encounter reporting, claims adjudication, and regulatory submission processes strongly preferred
• Experience researching, analyzing, and resolving complex encounter processing, reconciliation, regulatory compliance, claims, reimbursement, or operational issues
• Experience supporting encounter or claims operational improvement initiatives, system implementations, configuration validation, business requirements development, User Acceptance Testing (UAT), production support, or cross-functional projects
• Demonstrated experience performing data analysis, root cause analysis, reconciliation, and operational reporting to identify trends, resolve systemic issues, and improve operational performance
• Demonstrated ability to provide technical guidance, mentor staff, and serve as a subject matter expert while collaborating effectively with operational, technical, vendor, and business stakeholders

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s).