Job Description
- Job Description:
- lead end-to-end encounter submission processes, ensuring compliance with CMS and state Medicaid guidelines
- monitor, analyze, and resolve encounter submission errors using automated workflows and root cause analysis
- ensure accuracy, completeness, and timeliness of encounter data submissions to maximize acceptance rates and minimize rejections
- configure and validate Facets components across claims, benefits, pricing, and rules to ensure proper adjudication outcomes
- align encounter data processes with claims adjudication logic, 837/835 transaction flows, and EDI processing
- troubleshoot configuration and data issues impacting claims processing, encounters, and regulatory submissions
- validate and reconcile data across multiple systems to ensure accurate encounter submissions and minimize financial risk
- identify data gaps, mismatches, or revenue leakage risks related to Medicare Advantage and Medicaid
- implement improvements to increase encounter acceptance rates and reduce resubmissions
- support testing cycles (UAT, regression, validation) for new configurations or system enhancements
- Requirements:
- 5+ years of healthcare payer experience (Medicare and Medicaid)
- 5+ years of hands-on experience with Facets (TriZetto) and EDM across claims and configuration modules
- strong experience with: 837/835 transactions and EDI processing
- encounter data submissions and reconciliation
- working knowledge of claims payment systems
- claims adjudication processes
- experience working in consulting or client-facing environments
- ability to communicate with technical and non-technical staff
- Benefits:
- medical, dental, and vision coverage to employees and dependents
- a 401(k) plan with a generous employer match
- an employee stock purchase plan
- a generous Paid Time Off policy
- paid parental leave and adoption assistance
- wellness program supporting employee total well-being
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