Manager, Encounter Data Process Engineering

SUMMARY

The Manager, Encounter Data Process Engineering is responsible for designing, developing, and deploying encounter data specifications in compliance with CMS regulations. Monitors multiple projects simultaneously ensuring appropriate model designs and statistic methods are adopted. Assists in the planning and implementation of programs to improve revenue, control cost, improve quality and efficiency of services delivered to Medicare Advantage populations. This role is responsible for strategizing, innovating, analyzing, planning, organizing, budgeting, reporting, identifying equipment needs, and other functions that are required to maintain and operate an efficient and effective department. This role oversees a team of technical developers and analysts to drive strategic results aligned to a multi-billion-dollar annual revenue cycle.

Ideal performance in this role requires advance knowledge of HIPAA Electronic Data Interchange file formats, ANSI 837 ASC X12N or Version 5010 Data Models, and a diverse suite of technical languages including but not limited to SQL, Oracle, SAS, Tableau/Power BI, Python, CMS Risk Model Methodology.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Medicare Advantage vendor oversight, monitoring, and management for submission of encounters on behalf of the health plan.
• EDPS file tracking, trending, transfers to CMS to maximize acceptance rates.
• Facilitate error reconciliation with internal/external stakeholders
• Develops technical solutions to drive automation of error reconciliation and minimize manual interventions.
• Drive strategic results aligned to target goals/KPIs for risk scores and revenue targets
• Develops visual views to demonstrate EDPS program performance across lines of business
• Coordinates enterprise-wide with various stakeholders to reconcile, resolve, and resubmit claim encounters errors rejected by CMS within industry-defined timelines and deadlines
• Works closely with vendor submitter(s) to ensure compliance and timely submission.
• Responsible submission acceptance encounter and supplemental data rate to 98% target. 
• Plans, organizes, and directs activities of an assigned business area, including, but not limited to, planning, training, motivation, staff development, staff selection, and communication.
• Compiles and analyzes statistics and prepares activity related reports, manpower needs, and inventories and monitors all workflows within the unit.
• Manage, grow and develop a team of employee and contractor data engineers.
• Act as subject matter expert within functional area and educate consumers on data solutions.
• Build and operationalize Complex highly trusted and utilized data solutions.
• Develop for unit, functional, integrated and regression tests to ensure quality.
• Design and develop code, scripts and data pipelines that leverage structured and unstructured data integrated from multiple sources.
• Develop product deliverable documentation.
• Collaborate with agile team members to meet deadlines.
• Incorporate core architectural, data management, governance, security and quality practices and standards.
• Accountable for budget and expenses of functional areas and must ensure efficient delivery.
• Accountable for execution excellence of team including ensuring all governance, security, quality are followed.
• Mentor, develop and grow leadership talent.

EDUCATION AND EXPERIENCE 

Relevant combination of education and experience may be considered in lieu of degree.

• Bachelor’s degree in Computer Science, Information Systems, Engineering, Applied Mathematics, or related field; OR equivalent training with data technology, processes or solutions. 
• 6 years of data engineering or equivalent experience.
• 2 years of supervisory experience or a combination of project lead / supervisory experience
• Working with data in an insurance environment is preferred.
• Certification or progress toward certification is highly preferred and encouraged.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES 

• Must maintain advanced knowledge of HIPAA EDI file formats, ANSI 837 ASC X12N or Version 5010 Data Models
• Must maintain advanced knowledge of a diverse suite of technical languages. (SQL, Oracle, SASS, Tableau/Power BI, Python, CMS Risk Model Methodology, among others).
• Must have advanced knowledge of the CMS companion guide.
• Familiar with Electronic Data Interchange Architecture (EDI)
• Knowledge of Jira project management platform experience preferred.
• Knowledge of Risk Model Methodology preferred.
• Intermediate communication
• Intermediate relationship building
• Advanced problem-solving skills
• Intermediate change management
• Intermediate strategy development
• Proficient Execution Excellence
• Advanced knowledge of ETL tools and processes 
• Experience with statistics and data analysis, experience using various database platforms, data acquisition techniques, business intelligence and analysis tools.
• Advanced knowledge of DevOps fundamentals (build, release, test, monitor) 
• Intermediate knowledge of R, Python and SSRS preferred 
• Advanced knowledge of Big Data platforms such as Hadoop and DataBricks preferred 
• Familiarity or exposure to Java and .Net preferred
• Advanced knowledge of Cloud Data Platforms such as Snowflake 
• Advanced project management experience
• Strong Agile experience
• Advanced knowledge of database structures and data modeling
• Familiarity with database administration 

ADDITIONAL INFORMATION 

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.

 PAY RANGE: 

“Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $116,200 and $194,600.”

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis.  Nothing herein is intended to create a contract.

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