Shire Jobs

Compile and analyze Encounter data and understand the financial and clinical impact of changes and decisions to the business process to ensure Service Level Agreements (SLAs) are achieved. Provide analytical support and leadership for Claims Encounters Regulatory Data projects. Review Encounter rejections and provide resolution of minor to complex data issues or process changes. Provide Claims Encounter Subject Matter Expertise (SME) for both CMS and State agencies and internal CareSource impacted organizations. Direct responsibility for the design, testing and delivery of supporting processes to the business. Lead the claims data processes to ensure accuracy and compliance with CMS and state agencies. Provide support for other key claims data management and readiness to state and governing entities. Understand Claims Encounter Data requirements in detail to ensure claims data submissions achieve the required SLAs through requested changes. Identify inconsistencies and gaps to improve productivity, accuracy, data usability and streamline procedures and policies. Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements. Prepare and monitor various management and oversight metrics and reports as required. Lead Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions and improve regulatory report development with SIS. Contribute to and/or develop user stories or provide user story guidance for sprint planning. Understand claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLAs. Education Requirement: Bachelor's degree in Information Systems, Information Systems Technology, Data Analytics, related field, or foreign equivalent. Experience Requirement: Five (5) years of progressively responsible experience as a Developer in the healthcare or managed care industry. Candidate can work remotely from anywhere in the United States.