Manager, Risk Adjustment Encounter Data Reconciliation

Inland Empire Health Plan•Rancho Cucamonga, CA

5d•$118,602 - $157,144•Hybrid

About The Position

This role is a highly technical, data-driven, day-to-day operational leader responsible for ensuring the complete, accurate, and timely submission of all health plan encounter data to state and federal regulatory bodies (CMS and/or State Medicaid). Serving at the intersection of EDI infrastructure, data reconciliation, and risk adjustment compliance, this role executes strategies and transforms them into repeatable processes, dashboards, quality controls, and staff workflows that prevent revenue-impacting data dropouts. This position owns the daily, weekly, and monthly encounter data reconciliation lifecycles, manages staff performing sweeps and error resolution, tracks federal response files (999, 227CA, MAO-002), resolves clearinghouse rejections, and partners with internal teams to ensure valid HCCs successfully pass through all technical checkpoints. This role is critical to protecting and maximizing risk score integrity, ensuring regulatory compliance, and maintaining audit readiness. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

A minimum of five (5) years of progressive experience in managed care, healthcare EDI data management, or health plan operations, with a dedicated focus on encounter data reconciliation, RAPS/EDPS processing, or health plan claims billing
A minimum of three (3) years of leadership experience leading teams, projects, or technical workflows
Bachelor’s degree in business, public health, healthcare administration, informatics, or a related field from an accredited institution required
In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above
Must have a valid California Driver’s license
Advanced knowledge and deep familiarity of: CMS response reporting mechanisms, specifically MAO-002, MAO-004, and monthly RAPS error summaries
Encounter submission fundamentals: EDI 837P/837I; 835 remits; clearinghouse processes
Risk adjustment data lifecycle from clinical documentation, to coding, to claims, to EDI, to CMS acceptance
Advanced technical proficiency navigating standard healthcare EDI transactions (837P, 837I, 835), processing file layouts, and executing data sweeps.
Expert-level Microsoft Excel capability (e.g., nested logic functions, complex pivot tables, power query) is a mandatory requirement for daily operations.
Be an analytical problem solver with exceptional technical logic with a proven ability to analyze dense log files or data anomalies, isolate systemic errors, and partner with programmers/IT to implement automated fixes.
Strong interpersonal skills with the ability to translate highly dense, technical data extraction errors into simple, actionable operational requests for executive management or delegated IPA business leaders.
Proven ability to: Be detail oriented
Communicate with diplomacy
Lead staff while managing competing priorities and maintaining audit-ready standards
Build successful relationships across the organization
Identify and resolve problems, think creatively, strategically, and analytically

Nice To Haves

Master’s degree in business, public health, healthcare administration, informatics, or a related field from an accredited institution preferred
CRC, CPC, CCS‑P, or equivalent coding credential preferred
State-specific Medicaid encounter data processing models is a plus

Responsibilities

Manage daily technical and operational data streams for all risk adjustment submissions, ensuring seamless transaction flows from internal claims systems through 837P/837I EDI layouts into RAPS and EDPS (or state Medicaid systems)
Systematically ingest, track, and monitor daily and weekly federal response files, specifically monitoring the 999 (functional acknowledgment), 277CA (claim acknowledgment), MAO-002 (Encounter Data Processing Status), and RAPS return files
Lead technical root-cause analyses on rejected encounters. Develop and execute tactical corrective action plans to correct structural EDI loop errors, demographic mismatches, and invalid National Provider Identifiers (NPIs)
Govern the data-ingestion pipelines from delegated IPAs. Establish strict encounter submission schedules, audit their inbound encounter completeness, and enforce data transmission SLAs
Monitor claims from independent community clinics. Build internal operational sweeps to quickly identify valid clinical codes that were rejected at the front-end or clearinghouse level, manually or systematically correcting them to protect the plan's risk score
Generate data-gap reports for internal Provider Relations teams to address systemic, clinic-level billing errors (e.g., outdated electronic billing setups at independent clinics that cause continuous data dropouts)
Build and maintain monthly, end-to-end reconciliation dashboards that visually trace a medical code from the initial provider chart/encounter, through claims processing, to final CMS acceptance, ensuring zero technical data leaks
Act as the technical data lead during CMS RADV audits or OIG inquiries. Produce transaction trails and data-validation logs proving that submitted codes align with accepted regulatory files
Oversee the critical compliance process of submitting delete records for unconfirmed or un-vouched HCC codes, protecting the health plan from regulatory overpayment liabilities
Serve as the primary risk adjustment liaison to internal IT, Core Claims Ingestion, and EDI clearinghouse teams to optimize system mappings during annual CMS code updates (ICD-10 revisions) or system migrations
Partner with the Prospective Risk Adjustment team to track encounter submissions generated from In-Home Assessments (IHAs) or point-of-care vendor campaigns, ensuring these high-value data captures successfully bypass front-end rejections
Provide leadership, coaching, and guidance to the team to ensure high performance, accountability, and engagement. Support employee development, reinforce operational standards, and create a collaborative environment that aligns with departmental and organizational goals. Hire, train, and manage support staff, while monitoring and evaluating outcomes. Conduct performance reviews of each Team Member within IEHP guidelines
Maintain SOPs, workflow documents, and control checklists supporting audit readiness and risk adjustment compliance
Develop process improvements to reduce rejections, increase submission success rates, and enhance transparency into encounter flows
Perform any other duties as required to ensure Health Plan operations and department business needs are successful