Encounters Technical Lead

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MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Healthcare Administration, Business Administration, Finance, Economics, Information Systems, or a closely related field

EXPERIENCE:

1. Four (4) years of experience in encounter data management, risk adjustment, or related field within the healthcare industry.

2. Four (4) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities, quality outcomes and risk.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s Degree in Healthcare Administration, Business Administration, Finance, Economics, Information Systems, or a closely related field

EXPERIENCE:

1. Five (5) years of experience in encounter data management or related field within the healthcare industry.

2. Strong knowledge of CMS’ Encounter Data Processing System (EDPS) data files (837P, 837I, 277CA, MAO-001, MAO-002, MAO-004)

3. Knowledge of ICD Diagnosis, CPT, UB, HCFA coding and understanding

4. Understanding of CMS Medicare Regulatory Reporting

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Encounter Data Management:

• Oversee the end-to-end management of encounters data, including data ingestion, data cleansing, data transformation, and data integration. Develop and implement best practices for encounters data processing.
• Collaborate with internal and external stakeholders to establish effective data integration processes. Coordinate with IT teams and vendors to ensure smooth and accurate data exchange between systems and platforms.
• Design and develop encounter data models, ensuring they align with industry standards and organizational requirements. Optimize data models to support efficient data retrieval and analysis.
• Establish monitoring mechanisms to track the performance and efficiency of encounters data processes. Identify opportunities for optimization and implement appropriate measures to enhance system performance.

2. Technical Leadership:

• Provide technical expertise and guidance in encounters data management and analysis. Set clear technical objectives and expectations, and lead by example in delivering high-quality solutions.
• Ability to work collaboratively across many teams, prioritize demands from those teams, synthesize information received, and generate meaningful conclusions.
• Develop and implement training programs to enhance the skills and knowledge of the team.

3. Compliance and Reporting:

• Implement quality assurance processes and conduct regular audits to ensure data accuracy and integrity. Identify and resolve data-related issues promptly, collaborating with cross-functional teams as necessary.
• Utilize advanced analytics techniques to extract meaningful insights from encounter data. Work closely with analytics teams to define data requirements and support the development of analytical models and reports.
• Ensure compliance with all applicable regulatory requirements, guidelines, and contractual obligations related to Encounter Submissions (837P, 837I) and Response Files (277CA, MAO-001, MAO-002, MAO-004) via CMS’ Encounter Data Processing System (EDPS).
• Must possess current understanding of how compliance and quality programs such as Medicare STARS, HEDIS, and NCQA affect the Plan.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Working on a computer

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Remote

SKILLS AND ABILITIES:

1. Strategic thinking

2. Excellent written an oral communication

3. Demonstrated ability to analyze complex data sets, identify patterns, and derive actionable insights. Familiarity with statistical analysis and machine learning techniques is a plus.

4. Exceptional problem-solving and critical-thinking abilities, with a keen attention to detail. Ability to identify and resolve technical issues in a timely manner.

5. Attention to detail

6. Experience with Medicare and Medicaid products

7. Working knowledge of claims, utilization management, member, and/or provider data

8. Effective time management and organizational skills. Flexibility to adapt to changing priorities and business needs. Ability to thrive in a fast-paced and dynamic environment.

9. Work independently as well as in a team environment

10. Proficient with Microsoft Office

11. Proficiency in data integration tools and techniques. Strong knowledge of database management systems (e.g., SQL, NoSQL), data modeling, ETL processes, and data warehousing concepts. Experience with data visualization and analytics tools (e.g., SAS, Tableau, Power BI) is preferred.

12. Proven experience in leading technical projects. Strong interpersonal and communication skills to effectively collaborate with cross-functional stakeholders.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: