Phiture is hiring a Senior Claims & Encounters Analyst to assist with the operational functions for our government programs. This role requires deep expertise in regulatory compliance for Medicare and Medicaid, involving cross-functional collaboration to ensure process integrity and efficiency.
What You'll Do
- Support the team lead with day-to-day operational tasks related to claims processing, including testing, troubleshooting, documentation, and Encounter Data submissions.
- Oversee error handling and change management for Encounters, ensuring compliance with CMS, State, and client requirements.
- Conduct root cause analysis and implement corrective actions for operational issues, collaborating across departments to drive resolution.
- Monitor claims processing and adjudication trends, identifying systemic issues and opportunities for process improvement.
- Manage complex claims corrections, including retro-eligibility changes, COB adjustments, and other regulatory-driven updates.
- Serve as a subject matter expert (SME) for Medicare, Medicaid, and Exchange operations, supporting internal teams and external stakeholders.
- Support development and testing of operational processes, tools, and project deliverables.
- Establish and promote best practices for government programs operations, ensuring scalability and compliance.
- Support product strategy and service delivery by leveraging deep knowledge of Medicare & Medicaid regulatory environments.
- Stay current on CMS/State regulatory guidance updates, translating changes into actionable operational strategies.
- Mentor and guide analysts, fostering professional development and knowledge sharing.
- Maintain current knowledge of Medicare, Medicaid, and Exchange requirements to facilitate compliance of ongoing business operations.
- Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.
What We're Looking For
- 5+ years of experience in PBM or Health Plan operations, with a focus on Medicare Part D and/or Medicaid programs.
- Proven expertise in Medicare regulatory requirements and operational workflows, including PDE and Encounter Data.
- Advanced MS Excel skills (pivot tables, complex formulas, data modeling).
- Demonstrated ability to lead cross-functional projects and manage competing priorities in a fast-paced environment.
- Strong analytical and problem-solving skills, with a track record of driving operational improvements.
- Excellent communication and stakeholder management skills, including experience presenting to leadership.
- Deep understanding of CMS compliance requirements and audit readiness.
- Highly organized, detail-oriented, and committed to delivering high-quality work.
Nice to Have
- Familiarity with SQL or other data tools is a plus.
- Experience mentoring or managing junior team members is preferred.
Technical Stack
- MS Excel
- SQL
Team & Environment
You will assist the Claims and Encounters team lead with all operational functions.
Benefits & Compensation
- Salary: $85,000 - $95,000 USD
Work Mode
This is a hybrid role open to candidates in NYC, Denver, or Remote-US.
We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
