Note: The job is a remote job and is open to candidates in USA. Healthcare IS is seeking a highly experienced Encounter Data Manager (EDM) to support healthcare payer clients. This role focuses on end-to-end encounter data lifecycle management, ensuring compliance with CMS and state Medicaid guidelines, while also managing claims alignment and regulatory compliance.ResponsibilitiesLead end-to-end encounter submission processes, ensuring compliance with CMS and state Medicaid guidelinesMonitor, analyze, and resolve encounter submission errors using automated workflows and root cause analysisEnsure accuracy, completeness, and timeliness of encounter data submissions to maximize acceptance rates and minimize rejectionsConfigure and validate Facets components across claims, benefits, pricing, and rules to ensure proper adjudication outcomesAlign encounter data processes with claims adjudication logic, 837/835 transaction flows, and EDI processingTroubleshoot configuration and data issues impacting claims processing, encounters, and regulatory submissionsValidate and reconcile data across multiple systems to ensure accurate encounter submissions and minimize financial riskIdentify data gaps, mismatches, or revenue leakage risks related to Medicare Advantage and MedicaidImplement improvements to increase encounter acceptance rates and reduce resubmissionsPartner with Claims, EDI, IT, Enrollment, and Compliance teams to support encounter processing and issue resolutionTranslate business requirements into functional specifications and configuration designsProvide guidance to client stakeholders on best practices for encounter management and complianceDrive workflow automation and operational efficiencies in encounter submission and reconciliation processesSupport testing cycles (UAT, regression, validation) for new configurations or system enhancementsDocument configuration decisions, workflows, and system dependenciesSkills5+ years of healthcare payer experience (Medicare and Medicaid)5+ years of hands-on experience with Facets (TriZetto) and EDM across claims and configuration modulesStrong experience with 837/835 transactions and EDI processingEncounter data submissions and reconciliationClaims adjudication processesProven ability to analyze and resolve complex data and configuration issuesInterpret CMS and regulatory requirementsExperience working in consulting or client-facing environmentsExperience with TriZetto Encounter Data Management (EDM) solutionsBackground in risk adjustment, revenue cycle, or payment integrityStrong SQL/data analysis capabilitiesExperience supporting large-scale payer implementations, migrations, or transformationsCompany OverviewHealthcare IS is a consulting firm that extends its services in the areas of pharmacy, revenue cycle management and data warehousing. It was founded in 1998, and is headquartered in Dixon, California, USA, with a workforce of 51-200 employees. Its website is https://www.healthcareis.com/.
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