Manager, Risk Adjustment Encounter Data Reconciliation

Inland Empire Health Plans; Rancho Cucamonga (CA); On-site; USD 120,000 - 180,000; Full time

Benefits offered by this job

Competitive salary

On-site fitness center

Medical, dental, vision

Retirement options

Job summary

Inland Empire Health Plans (IEHP) seeks a Manager of Risk Adjustment Encounter Data Reconciliation to lead the data-driven lifecycle for encounter submissions. You will oversee reconciliation processes, error resolution, and regulatory reporting to CMS and State programs, ensuring HCC integrity and audit readiness.

You will mentor staff, coordinate with IT and operations, and drive dashboards and quality controls to prevent data dropouts and safeguard revenue.

Qualifications

• Five+ years in managed care, healthcare EDI data management, or health plan operations with focus on encounter data reconciliation/RAPS processing.
• Three+ years of leadership experience managing teams, projects, or technical workflows.
• Bachelor’s degree required; Master’s preferred; CRC/CPC/CCS-P credentials preferred.

Responsibilities

• Own daily, weekly, and monthly encounter data reconciliation lifecycles; manage sweeps and error resolution staff.
• Track federal response files (999, 227CA, MAO-002) and resolve clearinghouse rejections.
• Partner with internal teams to ensure valid HCCs pass through technical checkpoints; maintain audit readiness.

Skills

Analytical thinking

Leadership

Technical problem solving

Communication

Education

Bachelor’s degree in business/healthcare

Master’s degree preferred

CRC/CPC/CCS-P credential preferred

Tools

EDI 837P/837I

EDI 835

Clearinghouse processes

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Director of Risk Adjustment Prospective Programs, the Manager of Risk Adjustment Encounter Data Reconciliation 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.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary


• State of the art fitness center on-site


• Medical Insurance with Dental and Vision


• Life, short-term, and long-term disability options


• Career advancement opportunities and professional development


• Wellness programs that promote a healthy work-life balance
  
• Flexible Spending Account – Health Care/Childcare


• CalPERS retirement


• 457(b) option with a contribution match


• Paid life insurance for employees


• Pet care insurance

Education & Requirement

• 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
  
  
  • 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
  
  

Key Qualifications

• 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
  
  
  • State-specific Medicaid encounter data processing models is a plus
  
  
  • 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