Encounter Technical Data Specialist
Maryland Heights MO 63043 St Louis 1 14100 Magellan Plaza
Job DescriptionConducts data validation studies and responds to technical inquiries received from the Medicaid Managed Care Organzations (MCOs) contracted with a state program. Coordinates the receipt and adjudication of the pharmacy data that is required to be sent from the MCOs to the State's PBM (pharmacy benefit manager). Responds to technical and claims inquiries from the MCOs entailing the review of pharmacy encounter records that were not accepted at either the FTP gateway or POS system requiring further research in the pharmacy adjudication system and research in the applicable FTP files and servers. Determines where the file is failing in certain circumstances and also defines the error codes associated with potential claim issues. Also tests new files in concert with the MCO.
- Thoroughly and accurately researches, reports on and documents encounter claims that were processed by the MCO and submitted to the company.
- Conducts data validation studies to review pharmacy encounter records to validate encountered and billed for financial reimbursements by MCOs are timely, accurate and complete.
- The data validation study is also a routine method of review that assists the company in deterring, detecting and/or recovering inappropriate pharmacy benefit payments due to billing inaccuracies, claims processing and/or abusive and fraudulent practices.
- Ensures recovery of inappropriate payments of Federal, State and company health benefits to Providers and Consumers.
- Analyzes and reports data validation study findings by generating, tracking and following-up on corrective action letters.
- Conducts re-audits of MCOs to verify corrective actions were fully implemented and ensures correct processes going forward.
- Works with internal teams to set up and test new MCOs' claim submissions.
- Provides technical assistance to Providers' Clinical, Claims and Financial staff regarding CMS, FTP, POS system and State and Federal guidelines for proper medical records coding and billing practices.
- Serves as a medical records coding expert and advises Providers of Federal and State guidelines for proper procedure, revenue, and diagnostic coding.
- Develops and maintains working relationships with PNOs and Clinic employees, and all internal department employees to help facilitate full implementation.
General Job Information
TitleEncounter Technical Data Specialist
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date1/28/2019
Date Requisition Created1/28/2019
EducationAssociates: Business Administration, Associates: Computer and Information Science
License and Certifications - Required
License and Certifications - PreferredCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
Other Job Requirements
- 2+ years of claims and encounter transaction research experience at expert level.
- Familiar with current NCPDP D.0 Transaction Standards.
- Ability to deal with many functional areas of a national organization.
- Excellent verbal and written communication skills.
- Excellent research and analytical skills.
- Ability to identify encounter/claims processing and policy issues as they apply to corporate and contract policies.
- Strong spreadsheet and word processing skills.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled
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