1-3 years of experience
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Employment Type:
Full time
Job Category:
Health Care Provider
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Summacare | Akron, Ohio
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Job Description

SummaCare, Inc., a regional health insurance company based in Akron, Ohio, is looking for an analyst to maintain, support and reconcile Medicare (MC) claims, RAPS and encounter data before and after the data submission process to The Centers for Medicare & Medicaid Services (CMS).

Essential Functions & Responsibilities

  1. Understands MC risk score methodology, including: risk score calculations, Risk Adjustment Processing System (RAPS) procedures, Encounter Data Processing System (EDPS) rules, submission deadlines, error handling, ICD coding rules, MC administration claims rules, as well as supporting interfaces to claims, eligibility and provider Legacy systems.
  2. Analyzes, and reconcile claims and encounter data in regards to, claims data and Medicare billing rules, encounter submission process and return file process according to EDPS rules, X12 HIPAA complaint error file (999, 277, 837 formats), and determining processing rules for said files, and MAO-002 file and how the records in this file were filtered for the MAO-004 file.
  3. Reviews and audits data related to risk adjustment process as well as updating Part C Risk Adjustment (RA) database with said information. Conducts monthly audits and quality assurance testing of revenue realization activities, records results and recommends any corrective action. Audits risk adjustment factors to ensure accuracy as well as show trends in future payment due to the risk aspect.

Educational Requirements

Bachelor Degree or may substitute with 4 years of like experience.

Required Experience

3+ years in-depth working knowledge on recovering of Part C revenues.

Experience with the following IT applications also required: working knowledge of Amisys, Crystal Report Writer, Microsoft Office Products, MS SQL Server applications, SQL, Query Analyzer, and Enterprise Manager.

SummaCare is proud to be a Tobacco-Free Company. Applicants who test positive for nicotine during pre-employment testing are not eligible for hire.


Applicants must be eligible to work in the specified location

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