Mgr, Business Consultant

CVS Health•Work At Home-Pennsylvania, MA

3d•$60,300 - $132,600•Remote

About The Position

As the Dual Special Needs Plan (DSNP) business continues to expand, we are seeking an experienced Manager, Encounter Data & State Submission Operations to lead the end-to-end management of encounter and claims data submissions to state agencies. This role requires strong knowledge of healthcare claims processing, encounter reporting, the 837 claims transaction standard, and state-specific submission requirements. The Manager will be responsible for ensuring the accuracy, completeness, and timeliness of encounter data submissions while partnering closely with internal business and technical teams, as well as external vendors, to meet regulatory and operational requirements across multiple states.

Requirements

Minimum of 5 years of experience in healthcare claims operations, including medical claims processing and/or Medicare and Medicaid lines of business.
At least 2 years of experience overseeing secure data transmission processes utilizing SFTP and other file transfer technologies, with responsibility for monitoring, troubleshooting, and ensuring data integrity.
3+ years of experience in data management, including data validation, reconciliation, reporting, and issue resolution.
3+ years of leadership experience with demonstrated success managing workflows and leading, developing, and supporting teams within a healthcare operations environment.

Nice To Haves

2+ years experience working with states on DSNP encounter submissions.
2+ years experience working with the state of Florida on encounter submissions.
2+ years experience with vendor management.
Candidates located on the East Coast are strongly preferred.

Responsibilities

Serve as the subject matter expert for state-specific encounter data submission requirements and maintain comprehensive documentation of all applicable regulations and processes.
Lead the end-to-end management of encounter submissions, ensuring compliance with state and regulatory requirements.
Partner with technical teams and vendors to implement, monitor, and maintain processes that support accurate encounter data reporting and submissions.
Oversee 837 file transmission processes, ensuring files are submitted accurately, timely, and in accordance with state specifications.
Manage state response files, reconciliation activities, and error reporting to ensure all submitted transactions are accounted for and resolved.
Establish and maintain reporting, monitoring, and tracking processes for encounter submission performance, acceptance rates, and error trends.
Drive root cause analysis and coordinate corrective actions to resolve encounter submission errors and improve data quality.
Develop, document, and enhance operational processes related to encounter data management and state reporting.
Collaborate with cross-functional teams including Claims, IT, Compliance, Operations, Risk Adjustment, and vendor partners to ensure alignment and successful execution of encounter submission objectives.
Support audits, regulatory reviews, and internal compliance initiatives related to encounter data submissions.
Monitor changes in state and federal requirements and lead implementation efforts to maintain ongoing compliance.