The Encounter Data Submissions Program Manager will assist in the development of an end to end Encounter Data Submission and Reconciliation program, to include creation of program guide and standard operating procedures. The program manager will collaborate across teams to better understand and evaluate ROI of existing Alternate Submission Method (ASM) workstreams, as well as potential ROI improvements as a result of workflow efficiencies and enhancements. Additionally, once established, the program manager will oversee daily EDS and reconciliation processes.
This Manager will lead the design and implementation of Aledade’s end-to-end Encounter Data Submission and Reconciliation program, including the creation of comprehensive program guides and Standard Operating Procedures. You will act as a cross-functional leader, evaluating the ROI of existing Alternate Submission Method (ASM) workstreams and driving workflow enhancements that directly improve data accuracy and operational efficiency.
Once established, you will provide oversight of the daily EDS and reconciliation processes, ensuring that clinical encounter data—the lifeblood of value-based care—is accurately captured, validated, and submitted to payers and CMS with total integrity.
We are flexible with respect to geographic location, and the ideal candidate will be comfortable working remotely/work from home within the US.
Primary Duties
Assist in the development of programming documentation and SOPs, to include routine maintenance and update of program documents
Identify and establish ASM process with additional eligible payers
Provide support to CSO in efforts to increase practice “opt-in” to ASM processes
Create and transmit ASM files to all relevant payers on an established cadence
Maintain annual CMS and payer submission deadlines
Maintain and update payer specific ASM templates annually
Maintain and update payer specific submission methods annually
Reconcile ASM record submissions with payer and CMS EDS files
Establish routine reconciliation process with payer and CMS files
Integrate accepted ASM submitted diagnosis data into existing risk reporting dashboards
Provide ongoing monitoring of provider diagnosis submission and truncation trends
Develop process for consistent monitoring of existing dropped diagnosis and truncation dashboards for early identification of diagnosis submission errors
Collaborate with senior leadership and legal partners to ensure continued compliance with regulatory requirements pertaining to submission of “add” and “delete” diagnoses
Develop a process to identify and submit diagnoses appropriately identified through routine CDI chart audits.
Conduct annual ROI evaluation of ASM processes to include both submission of “dropped” diagnoses, and retrospective chart audit projects
Other duties as assigned.
Minimum Qualifications
Bachelor's degree in Business, Finance, Information Technology, Analytics, Operations, or a related field
4+ years of experience with Medicare Advantage or ACA encounter data processes and/or risk adjustment experience with a Payer, Vendor or Provider Organization
1+ years of X-12 837 data knowledge
Strong analytical skills with a proven ability to interpret complex data sets and identify key insights
Ability to develop and present information to Senior Leadership
Working knowledge of SQL: writing, creating and/or running queries
Software Proficiency: Proficiency in using common business software such as Microsoft Office Suite (Word, Excel, PowerPoint), collaboration tools (e.g., SharePoint), and project management software (e.g., Jira, Smartsheet)
Preferred knowledge, skills, and/or abilities
Excellent communication and presentation skills, both written and verbal
Business Process Reengineering (BPR): Familiarity with BPR principles and methodologies to radically redesign business processes for improved performance, efficiency, and customer satisfaction
Medicare claims experience
Fundamental understanding of relational databases
Physical Requirements
Prolonged periods of sitting at a desk and working on a computer.
