The Claims Encounter/ Reimbursement Specialist is responsible for the accurate and timely submission, reconciliations, and auditing of Medicare encounter data in compliance with CMS regulations. This position ensures all encounter data is complete, accurate, and meets federal and state regulatory requirements, supporting the organization’s risk adjustment and revenue cycle processes. This position will also support the reimbursement fee schedules, reimbursement methodology and network set process within the claims system to ensure all claims reportable data files are accurate and timely.
Purpose:
The Claims Encounter/Reimbursement Specialist is accountable for and oversees the following tasks:
- Collect, review, and validate Medicare Advantage (MA) and Medicaid encounter data from internal systems and external partners (e.g., providers, vendors).
- Submit accurate encounter data files to CMS via appropriate formats (e.g., EDI 837 format), with appropriate transmission methods (Clearinghouses, SFTP folders etc.)
- Perform regular audits and reconciliations of submitted encounter data to ensure data integrity and identify discrepancies or rejections.
- Investigate and resolve data errors or rejections using CMS response files and internal systems.
- Collaborate with IT, claims, and provider teams to improve data submission quality and resolve data issues.
- Monitor CMS communications and updates related to encounter data submission guidelines and compliance.
- Document and maintain SOPs for encounter submission workflows and data correction procedures.
- Assist in preparing reports related to encounter submission performance, error rates, and compliance metrics.
- Support Medicare Risk Adjustment processes by ensuring encounter data supports HCC coding requirements.
- Uploads/Add/Modify/Terminate fee schedules linked to a Provider Network set within 98% accuracy
- Maintain Network/Network Sets as applicable by active Health Plans
- Maintain Provider Reimbursement Modules within the claims system including but not limited to: Provider Medical Groups, Payor, Payor Benefit Contracts/Benefit Plans etc.
- Maintain U&C sets for OON/OOA/Gold Card agreements within the claims system
ESSENTIAL JOB FUNCTIONS AND DUTIES:
- Working with EDI transactions, particularly 837I and 837P format files
- Working in Health Plan Encounter Platforms (Availity, Finthrive, P-N-T, Optum etc.)
- Oversee and present detailed data with the ability to manage large datasets and reconcile discrepancies
- Working with different response files, reporting tools in relation to encounters/fee schedule processes
- Participating in monthly health plan meetings to discuss encounter logs/issues/escalations
- Participating in external/internal audit encounter reviews/submission of packets
REQUIRED QUALIFICATIONS:
- 3-5 years of direct experience in Healthcare Information Management or related Healthcare Insurance and Claims Adjudication is strongly preferred
- 2-4 years of experience in healthcare data processing, claims, or encounter data submission; experience with Medicare Advantage is strongly preferred
- Working knowledge of CMS regulations, risk adjustment and encounter data submission requirements
- Working knowledge of fee schedule, network design with Medicare
- Detailed knowledge of multiple benefit plan designs including Network designs for DSNP, MA HMO, POS, PPO etc.
Skills and Abilities:
- Proficiency with EDI transactions, particularly 837 formats.
- Basic SQL experience is a plus.
- Experience with Medicare systems, or other CMS platforms.
- Strong analytical and problem-solving skills.
- Detail-oriented with the ability to manage large datasets and reconcile discrepancies.
- Excellent communication and collaboration skills.
- Familiarity with healthcare claims systems (e.g., Facets, QNXT, Epic) is a plus.
- Proficient in Excel, Power BI and other reporting tools.
Job Type
- Full-time
- Remote - United States
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.