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Job Summary:

Leads the organization, analysis, correction and recommendation of solutions to internal and external stakeholders regarding encounter data issues, policies, processes, requirements, and records.

Primary Job Responsibilities:

• Represents the encounter team to leadership by presenting reports, project progress, metrics, deliverables, and other encounter-related updates.
• Leads and oversees the correction of rejected encounters by researching, reviewing, and interpreting encounter data, identifying potential issues, and ensuring corrections comply with internal and external processing guidelines and best practices.
• Monitors, manages, and audits encounter submissions to ensure timely, accurate file submission and processing.
• Leads encounter implementation activities for new customer onboarding, driving cross-functional coordination and ensuring deliverables align with internal standards, regulatory expectations, and external customer requirements.
• Serves as a key subject matter expert during internal and external audits by coordinating requested materials, completing audit responses, preparing supporting documentation, presenting findings, and monitoring audit-related reports to demonstrate compliance with audit requirements.
• Provides oversight of electronic data interchange (EDI) and X12 data exchange compliance, ensuring encounter transactions adhere to applicable industry regulations, HIPAA requirements, and partner-specific mandates.
• Monitors the development, implementation, maintenance, and application of encounter policies, procedures, error libraries, and reporting tools to correct rejected encounters and support daily and weekly operational oversight.
• Monitors and evaluates related processes to ensure internal and external requirements are met, represents the encounter team when partnering with functional areas to maintain claims system support tables, and coordinates data entry or general data maintenance for eligibility, providers, fee sets, benefits and related records.
• Oversees root cause analysis for encounter errors and reviews results, processes, and/or system programming with other departments to minimize repeat issues, identify opportunities for improvement, and recommend solutions.
• Establishes and maintains strong relationships with internal and external plans, partners, and other stakeholders to correct, prevent, and resolve encounter errors.
• Serves as lead subject matter expert and key internal consultant on encounter data, policies, processes, compliance, and corrections, develops training for internal stakeholders regarding regulatory changes, and coordinates and leads encounter data and compliance meetings.
• Oversees compliance with data integrity policies for all system configurations.
• Leads the recruitment process for new encounter data staff, including interviewing, selection, onboarding and training.
• Assures adherence to company policies, internal controls, regulatory compliance, and general principles.
• Communicates and manages encounter deliverables to ensure compliance with state requirements and contract SLAs.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Hybrid

Minimum Requirements:

Position requires a bachelor’s degree in business administration or a related field and seven years of experience identifying, analyzing, or resolving business, system, or process issues in the administration of health plan benefits, including experience with encounter data processing. Experience administering Medicare and/or Medicaid programs and applying Centers for Medicare and Medicaid Services regulations and guidelines is preferred. Will accept any suitable combination of education, training, or experience.

 Position requires experience with EDI formats, database applications, analytical reporting tools, and Microsoft Office applications; strong verbal and written communication skills; strong analytical skills; ability to lead cross-functional work; the ability to manage multiple assignments with competing deadlines; strong interpersonal skills, including the ability to represent and present to organizational leadership; and the ability to identify and resolve complex problems using independent judgement.