Encounter Data Submissions Program Manager

This is a fully remote position, open to applicants in Maryland, +1 more state.

📋 Description

• Assist in the development of a comprehensive Encounter Data Submission and Reconciliation program.

• Create, update, and maintain program documentation along with Standard Operating Procedures.

• Identify and establish Alternate Submission Method (ASM) processes with qualifying payers.

• Support initiatives to enhance practice participation in ASM processes.

• Generate and send ASM files to pertinent payers on a predetermined schedule.

• Adhere to annual CMS and payer submission deadlines.

• Annually update and maintain payer-specific ASM templates and submission methods.

• Reconcile ASM record submissions with payer and CMS Encounter Data System (EDS) files.

• Establish routine reconciliation processes with payer and CMS files.

• Integrate accepted ASM diagnosis data into existing risk reporting dashboards.

• Monitor trends in provider diagnosis submissions and truncation.

• Develop monitoring processes for dropped diagnosis and truncation dashboards.

• Collaborate with senior leadership and legal teams to ensure compliance with regulations.

• Create processes to identify and submit diagnoses based on CDI chart audits.

• Perform annual Return on Investment (ROI) evaluations of ASM processes.

• Oversee daily EDS and reconciliation operations once the program is established.

• Ensure accurate capture, validation, and submission of clinical encounter data to payers and CMS.

⛳️ Requirements

• Bachelor's degree in Business, Finance, Information Technology, Analytics, Operations, or a related discipline.

• Over 4 years of experience with Medicare Advantage or ACA encounter data processes and/or risk adjustment within a Payer, Vendor, or Provider Organization.

• At least 1 year of knowledge related to X-12 837 data.

• Strong analytical capabilities with a demonstrated ability to interpret complex data sets and extract key insights.

• Ability to develop and deliver presentations to Senior Leadership.

• Proficient in SQL, including writing, creating, and/or executing queries.

• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint), collaboration tools (e.g., SharePoint), and project management software (e.g., Jira, Smartsheet).

• Exceptional written and verbal communication skills, along with strong presentation abilities.

• Familiarity with Business Process Reengineering (BPR) principles and methodologies.

• Experience with Medicare claims.

• Basic understanding of relational databases.

• Ability to sit for extended periods at a desk and work on a computer.

🏝️ Benefits

• Flexible work schedules and the option to work remotely are available for many positions.

• Health, dental, and vision insurance coverage up to 80% for employees, dependents, and domestic partners.

• Comprehensive time-off plan, including 21 days of PTO during your first year.

• Two paid volunteer days and 11 paid holidays each year.

• 12 weeks of paid parental leave for all new parents.

• Six weeks of paid sabbatical after six years of service.

• Educational Assistant Program and Clinical Employee Reimbursement Program.

• 401(k) plan with up to a 4% match.

• Stock options.

• Commitment to equal opportunity employment and fostering a diverse, inclusive workplace.