Encounters Technical Lead

WVU Medicine•Home Work - VA (Remote), VA

8d•Remote

About The Position

Come join Peak Health to help launch a Medicare Advantage plan. We are seeking a highly skilled and experienced professional to join our organization as an Encounters Technical Lead. Reporting to the Manager, Encounters & Risk Adjustment, the Encounters Technical Lead will play a pivotal role in our organization by overseeing the technical aspects of encounters data management and analysis. This role requires a strong understanding of healthcare encounters data, as well as expertise in data integration, data modeling, and data analytics. The successful candidate will collaborate closely with cross-functional teams to ensure accurate and efficient processing of encounters data.

Requirements

Bachelor’s Degree in Healthcare Administration, Business Administration, Finance, Economics, Information Systems, or a closely related field
Four (4) years of experience in encounter data management, risk adjustment, or related field within the healthcare industry.
Four (4) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities, quality outcomes and risk.
Strategic thinking
Excellent written an oral communication
Demonstrated ability to analyze complex data sets, identify patterns, and derive actionable insights.
Exceptional problem-solving and critical-thinking abilities, with a keen attention to detail.
Attention to detail
Experience with Medicare and Medicaid products
Working knowledge of claims, utilization management, member, and/or provider data
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.
Work independently as well as in a team environment
Proficient with Microsoft Office
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.
Proven experience in leading technical projects.
Strong interpersonal and communication skills to effectively collaborate with cross-functional stakeholders.

Nice To Haves

Master’s Degree in Healthcare Administration, Business Administration, Finance, Economics, Information Systems, or a closely related field
Five (5) years of experience in encounter data management or related field within the healthcare industry.
Strong knowledge of CMS’ Encounter Data Processing System (EDPS) data files (837P, 837I, 277CA, MAO-001, MAO-002, MAO-004)
Knowledge of ICD Diagnosis, CPT, UB, HCFA coding and understanding
Understanding of CMS Medicare Regulatory Reporting
Familiarity with statistical analysis and machine learning techniques is a plus.
Ability to identify and resolve technical issues in a timely manner.
Experience with data visualization and analytics tools (e.g., SAS, Tableau, Power BI) is preferred.

Responsibilities

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.
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.
Develop and implement training programs to enhance the skills and knowledge of the team.
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.