GENERAL SUMMARY OF POSITION

Ensures that accurate and complete enrollment and encounter data resides within the health plan Enterprise Data Warehouse (EDW) and is successfully transmitted to the Maryland Department of Health (MDH) and/or Department of Health Care Finance (DHCF). Researches and resolves enrollment discrepancies identified by the health plan. This includes identifying and reporting individuals who no longer meet eligibility requirements (duplicate members, moved out of state, deceased etc). Ensures downstream vendors have accurate eligibility and monitors enrollment reconciliation process between BPaaS vendor and the delegated vendors. Includes working with BPaaS vendor to resolve eligibility issues. Evaluates encounter data and identifies errors, including those created by operational, claims, and eligibility processes. Researches, analyzes, summarizes, and categorizes all types of encounters based on response files from MDH/DC DHCF, as appropriate. Works closely with other internal departments, delegated vendors, and government agencies to monitor and communicate that the paid and denied claims adjudicated are completely and accurately submitted and processed to the MDH and/or DHCF in a timely manner, as appropriate. Needs to understand the overall data, process flows, and provider data specifications used within Maryland/DC, and works with the Information Technology, Medical Economics and Analytics teams to create targeted and ongoing reports to track data accuracy and timeliness. Works under moderate supervision. Serves as the business lead for Interoperability requirements in Maryland/DC. This includes managing the relationships with the delegated vendor hosting the Interoperability software and managing the onboarding of third-party applications. We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.

EDUCATION

• High School Diploma or GED or equivalent required or
• Bachelor’s degree in Computer Science, Public Health, Healthcare Informatics, Health Administration, Statistics, or other relevant discipline preferred

EXPERIENCE

• 3-4 years 4 years of related experience required and
• Experience performing encounter data and enrollment reconciliations in a health plan organization, healthcare claims data, health plan enrollment data, resolving data reconciliation/integrity issues. required and
• Experience working with state medicaid agencies related to enrollment and encounter data errors. required and
• Experience with management and fitness of data elements within an enterprise data warehouse for both content and metadata. required

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of encounter data processes, files, etc.
• Advanced proficiency in personal computer programs, including MS Excel required and enterprise database programs (e.g. SQL).
• Proficiency in Tableau.
• Familiarity with a data warehouse environment required.
• Knowledge of medical terminology and/or experiences with CPT and ICD-10 coding.
• Ability to identify basic problems and procedural irregularities, collect data, establish facts and draw valid conclusions.
• Strong aptitude for critical thinking and demonstrated data skills.
• Excellent verbal and written communication skills.
• Detail oriented; able to work independently and set priorities.Knowledge of FHIR Data Interoperability via APIs.
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  This position has a hiring range of $70,428 - $131,310

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
• Ensures compliance with policies and procedures and governmental/accreditation regulations.
• Reconciles enrollment data and encounter data within the Enterprise Data Warehouse.
• Reconciles enrollment data with delegated vendors
• Serves as primary point of contact with MDH/DHCF on encounter data issues. Reports, tracks, resolves and trends enrollment discrepancies to MDH. This includes issues identified by BPaaS vendor and/or other delegated vendors.
• Retrieves, compiles, reviews, and ensures the accuracy of encounter data from the EDW and delegated vendor sources, using an 837-file format. Completes complex root cause analysis and research of encounter errors to generate corrections in a timely manner to provide an accurate picture of medical expense and avoid penalties from the State.
• Accesses data from the EDW using a variety of tools such as, Tableau, MS Excel, SQL. Works closely with IT and Medical Economics to ensure data completeness, data accuracy and data availability. Monitors encounter data integrity of various databases and creates monthly, quarterly and ad-hoc reports.
• Summarizes large volumes of encounter data in analytical reports that include tables, graphs, qualitative and quantitative analyses for management review and use.
• Programs using SQL or other appropriate software to generate reports based on input/direction from management and other report users.
• Collaborates with other departments and vendors to identify missing data, errors or other anomalies; works with them to correct these encounter data errors, gather necessary information and provide guidance on regulatory reporting needs.
• Initiates and maintains internal contacts to secure current/correct encounter data necessary for clear presentations of all reports, special projects, etc.
• Reviews and identifies trends and variances in encounter data and reporting. Researches findings and determines the appropriateness of elevating identified issues to leadership for further review/evaluation/action.
• Manages the Interoperability process in Maryland/DC to ensure compliance with all state and federal regulations. Serves as data steward for Interoperability integration projects, providing accurate and timely requirements, prioritization, testing and documentation.
• Ensures delegated vendor adheres to all Interoperability requirements and monitors system functionality. Manages all system upgrades and enhancements
• Assist in the development and implementation of processes to improve data quality within the data class
• Develop and maintain key relationships with all impacted business areas and external partners in support of Interoperability compliance
• Collaborates with MFC IT to ensure claims and enrollment data continue to flow through to Interoperability vendor
• Collaborates with MedStar Health IT security in the vetting and approval of third party applications for Interoperability.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
• Performs special projects and other duties, as needed.