Claims & Encounters Analyst
Capital Rx
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteSalary
💰 $70,000 - $80,000 per year
Job Level
JuniorMid-Level
About the role
- Support the team lead with day-to-day operational tasks related to claims processing, including testing, troubleshooting, documentation and Encounter Data submissions.
- Oversee error handling and change management for Encounters, ensuring compliance with CMS, State and client requirements.
- Conduct root cause analysis and implement corrective actions for operational issues, collaborating across departments to drive resolution.
- Monitor claims processing and adjudication trends, identifying systemic issues and opportunities for process improvement.
- Manage complex claims corrections, including retro-eligibility changes, COB adjustments, and other regulatory-driven updates.
- Serve as a subject matter expert (SME) for Medicare, Medicaid and Exchange operations, supporting internal teams and external stakeholders.
- Support development and testing of operational processes, tools, and project deliverables.
- Establish and promote best practices for government programs operations, ensuring scalability and compliance.
- Support product strategy and service delivery by leveraging deep knowledge of Medicare & Medicaid regulatory environments.
- Stay current on CMS/State regulatory guidance updates, translating changes into actionable operational strategies.
- Mentor and guide analysts, fostering professional development and knowledge sharing.
- Maintain current knowledge of Medicare, Medicaid and Exchange requirements to facilitate compliance of ongoing business operations.
- Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.
Requirements
- 2+ years of experience in PBM or Health Plan operations, with a focus on Medicare Part D and/or Medicaid/Exchange programs.
- Proven expertise in Exchange, Medicaid, and Medicare regulatory requirements and operational workflows, including PDE, and Encounter/Edge Data.
- MS Excel skills (pivot tables, complex formulas, VLOOKUP’s)
- Exhibited proficiency in collaborating across functional teams and managing competing priorities within a dynamic and fast-paced work environment.
- Analytical and problem-solving skills, with a track record of driving operational improvements.
- Excellent communication and stakeholder management skills, including experience presenting to leadership and clients.
- Foundational understanding of Federal/State compliance requirements.
- Highly organized, detail-oriented, and committed to delivering high-quality work.
Benefits
- Health insurance
- Flexible work arrangements
- Professional development
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
claims processingtroubleshootingdocumentationroot cause analysisclaims correctionsregulatory updatesPDEEncounter DataMS ExcelVLOOKUP
Soft skills
collaborationproblem-solvingcommunicationstakeholder managementmentoringorganizational skillsattention to detailprofessional developmentdynamic work environmentprocess improvement