Claims & Encounters Analyst

Location: Hybrid (Local to NYC or Denver areas) or Remote-US

Position Summary:

The Claims and Encounters Analyst will provide comprehensive support for all operational functions associated with government programs. This role necessitates a fundamental understanding of regulatory and compliance standards governing claims, encounter, and PDE operations within the programs in which we engage. Collaborative cross-functional efforts will be paramount to uphold integrity and optimize the efficiency of all government program processes. This individual will be responsible for day-to-day activities, including reconciling internal data with data produced by governing agencies and reconciling Encounter and PDE data

Position Responsibilities:

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  Support the team lead with day-to-day operational tasks related to claims processing, including testing, troubleshooting, documentation and Encounter Data submissions.

  
  
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  Oversee error handling and change management for Encounters, ensuring compliance with CMS, State and client requirements.

  
  
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  Conduct root cause analysis and implement corrective actions for operational issues, collaborating across departments to drive resolution.

  
  
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  Monitor claims processing and adjudication trends, identifying systemic issues and opportunities for process improvement.

  
  
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  Manage complex claims corrections, including retro-eligibility changes, COB adjustments, and other regulatory-driven updates.

  
  
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  Serve as a subject matter expert (SME) for Medicare, Medicaid and Exchange operations, supporting internal teams and external stakeholders.

  
  
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  Support development and testing of operational processes, tools, and project deliverables.

  
  
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  Establish and promote best practices for government programs operations, ensuring scalability and compliance.

  
  
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  Support product strategy and service delivery by leveraging deep knowledge of Medicare & Medicaid regulatory environments.

  
  
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  Stay current on CMS/State regulatory guidance updates, translating changes into actionable operational strategies.

  
  
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  Mentor and guide analysts, fostering professional development and knowledge sharing.

  
  
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  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.

Required Qualifications:

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  5+ yearsof experience in PBM or Health Plan operations, with a focus on Medicare Part D and/or Medicaid programs.

  
  
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  Proven expertise in Medicare regulatory requirements and operational workflows, including PDE, and Encounter Data.

  
  
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  AdvancedMS Excelskills (pivot tables, complex formulas, data modeling); familiarity with SQL or other data tools is a plus.

  
  
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  Demonstrated ability to lead cross-functional projects and manage competing priorities in a fast-paced environment.

  
  
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  Strong analytical and problem-solving skills, with a track record of driving operational improvements.

  
  
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  Excellent communication and stakeholder management skills, including experience presenting to leadership.

  
  
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  Experience mentoring or managing junior team members is preferred.

  
  
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  Deep understanding of CMS compliance requirements and audit readiness.

  
  
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  Highly organized, detail-oriented, and committed to delivering high-quality work.