JOB SUMMARY

Responsible for the end-to-end management of claims and encounter data within electronic data processing systems (EDPS).  This role ensures accuracy, compliance and operational efficiency to support critical revenue and claims streams.  The Premium Senior Analyst validates, submits, monitors transactions, implements layout changes, resolves errors, and coordinates with other operational areas when process dependencies arise. The role drives process enhancements to improve efficiency and effectiveness.  Additionally, supports data-driven decision making by analyzing trends and patterns in complex healthcare data, developing reports and analyses for management, and participating in operational and financial reconciliations as needed. The role requires proficiency in analytical tools such SQL, Excel and Power BI. Detail-oriented with strong analytical skills.  Ability to manage complex, end to end process independently.  Strong communication skills for cross-departmental coordination. and a strong commitment to delivering the highest level of customer service are also required.

ESSENTIAL FUNCTIONS

• Lead end to end submission, validation, and optimization of healthcare transactions (claims and encounters) across enterprise systems (e.g. MMIS, EDPS, and related platforms)
• Analyze, investigate, and resolve transaction rejections, including root cause identification, solution design, and coordination with cross-functional teams to drive resolution and improve acceptance rate
• Ensure accuracy, completeness, and compliance of submitted data, aligning with regulatory requirements and internal business rules 
• Monitor transactions workflows and data pipelines, proactively identifying issues that may impact processing, acceptance, risk capture, or downstream reimbursement
• Collaborate with operational, clinical, and technical teams to improve data quality, documentation, and submission accuracy
• Support risk adjustment initiatives by ensuring proper capture and submission of diagnosis and encounter data impacting risk score
• Develop and deliver recurring and AH HOC analytical reports to support leadership decision making, highlighting trends, risks, and opportunities
  Identify process improvement opportunities and lead continuous improvement initiatives, including workflow optimization, standardization, and automation opportunities
• Act as subject matter expert in transaction lifecycle processes, providing guidance and recommendations on performance improvement and risk mitigation
• Lead coordination and follow up with internal and external stakeholders to ensure timely resolution of issues impacting transaction acceptance and processing
• Ensure timely implementation of system updates, regulatory changes, and new business requirements impacting transaction processing
• Operate with a high degree of autonomy in managing daily operations, prioritizing workload, and driving issue resolution across multiple dependencies 
• Monitor industry trends, regulatory guidance and payer requirements assessing impact to transaction processes and ensuring timely alignment
• Perform additional analyses and support special projects as needed, aligned with departmental and organizational priorities 

EDUCATION

Bachelor’s degree in a related quantitative field with three (3) to five (5) years of relevant experience. Experience in claim processing, data analysis, and Medicaid programs, including familiarity with MMIS, EDPS, or similar transaction processing systems is preferred.

LICENSES AND CERTIFICATIONS

COMPETENCIES