Under the general direction of the Director of Claims the Paid Claims Reporting Specialist will be responsible for facilitating the successful transmission and acceptance of all encounter data by AHCCCS. This may include pended encounter research and correction, file creation and audit prior to submission to AHCCCS, and the identification of claims processing problems that my impact the encountering of clean and accurate data to the State.
Creates monthly cycle encounter files and submits to AHCCCS via file transfer protocols. Reviews, researches and corrects encounter editing reports. Investigates pends to determine if correction is the responsibility of the plan or if they are due to AHCCCS system conditions.
Maintains encounter files along with all documentation that supports the processing cycle. Assists in drafting and updating or encounter policies and procedures as needed. Tracks the encounter pends and evaluates any training/system needs and communicates suggestions for process improvements to claims management and appropriate IS personnel.
Plans, implements, maintains and evaluates projects as related to pended encounters.
Responsible for planning the day to day tasks to be completed within the unit; trains and otherwise acts as a resource for the other encounter specialist in the department. Assists managerial staff with evaluation of error data.
Acts as a liaison with all internal and external resources, including third party interface programmers and technical advisors.
Performs immediate follow up on State imposed sanctions with documented refutation when appropriate.
Assists with special projects as needed, monitors and reports to the management staff on a regular basis regarding status of projects.
Responsible for reconciliation process with final accountability that all encounters have been submitted to the governing agency.
Knowledge, skills and abilities as normally obtained through the completion of a bachelors degree or equivalent experience preferred. Five years claims processing experience, preferably with AHCCCS experience.
Knowledge of AHCCCS encounter regulations and guidelines; strong written and verbal communication skills. Strong working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint). Good organizational/analytical skills; strong attention to details.
Ability to plan/direct projects and to analyze and trend system changes. Ability to communicate with AHCCCS technical and managerial personnel to identify system problems related to both procedures and programming. Ability to assist in the scheduling of daily tasks and to train new encounter specialists. Knowledge of data transfer protocols, ability to manage data files with mainframe system experience (non-Microsoft).
Five years claims processing experience, preferably with AHCCCS preferred. Three years encounter experience with AHCCCS preferred. IDX experience, two years IDX or other claims systems experience preferred.
Additional related education and/or experience preferred.
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