Encounter Data Specialist

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Job Summary:

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do - from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description:

Supports accurate and compliant encounter data operations by identifying, analyzing, and resolving rejected records and other encounter data issues; improving related policies, processes, requirements, and records; and collaborating with internal and external stakeholders to strengthen data quality and submission outcomes.

Primary Job Responsibilities:

• Researches, analyzes, corrects, and resubmits rejected encounter records in accordance with internal and external guidelines, contractual service level agreements, and applicable state and federal requirements.
• Reviews, interprets, monitors, and audits encounter data and file submissions to identify issues, validate accurate and timely processing, and ensure compliance with applicable requirements.
• Develops, maintains, and updates encounter policies, procedures, rejection correction guidance, error libraries, and routine operational reports.
• Monitors encounter processes and system configuration for compliance with internal and external requirements and data integrity policies; collaborates with functional areas to maintain claims system support tables; and updates eligibility, providers, fee sets, and benefit information for related records.
• Supports new customer implementation by coordinating encounter-related activities, tracking assigned tasks, and helping ensure requirements are met in alignment with internal processes and external expectations.
• Supports internal and external audits by gathering requested information, completing assigned audit documentation, providing supporting materials, communicating findings or updates, and coordinating completion of audit reports with other departments.
• Reviews electronic data interchange (EDI) and X12 data exchanges to help ensure compliance with applicable industry standards, HIPAA requirements, and partner-specific encounter data guidelines.
• Identifies configuration issues, encounter error and rejection trends, and file failures; conducts root cause analysis and collaborates with internal departments to recommend, develop, and test corrective actions, audit reports, and processes improvements that strengthen data integrity and reduce recurring rejections.
• Prepares and presents recurring metric reports to clients and other stakeholders, translating technical findings to non-technical audiences.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Minimum Requirements:

Position requires a bachelor’s degree in business administration or a related field and five years of experience identifying, analyzing, or resolving business, system, or process issues in the administration of health plan benefits. Experience with encounter data processing is preferred. Experience administering Medicare and/or Medicaid programs and applying Centers for Medicare and Medicaid Services regulations and guidelines is also preferred. Will accept any suitable combination of education, training, or experience.

Position requires knowledge of EDI formats, SQL, database applications, analytical reporting tools, and Microsoft Office applications; strong verbal and written communication skills; strong analytical skills; ability to manage multiple assignments with competing deadlines; ability to work independently and collaboratively; and the ability to identify and resolve complex problems using independent judgment.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.