Manager, Risk Adjustment Encounter Data Reconciliation

Inland Empire Health Plan

Rancho Cucamonga (CA)

Hybrid

USD 119,000 - 157,000

Full time

4 days ago

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Benefits offered by this job

Competitive salary

On-site fitness center

Medical Insurance with Dental and Vis

Life, short-term, and long-term-dis

Career advancement opportunities and专业

Wellness programs

Flexible Spending Account - HealthCare

CalPERS retirement

457(b) matching

Paid life insurance

Pet care insurance

Job summary

Inland Empire Health Plan (IEHP) seeks a highly technical leader to manage Risk Adjustment Encounter Data Reconciliation. You will oversee daily to monthly data lifecycles, ensure complete submissions to CMS/state systems, and drive quality controls, audits, and staff workflows to maximize risk score integrity.

The role reports to the Director of Risk Adjustment Prospective Programs and requires strong EDI, data reconciliation, and regulatory compliance expertise, with hybrid work in Rancho

Qualifications

Minimum five (5) years of progressive experience in managed care, EDI data management, or health plan operations.
Minimum three (3) years of leadership experience leading teams or technical workflows.
Bachelor’s degree required; in lieu of degree, four additional years of relevant work experience accepted.
Master’s degree preferred; coding credentials preferred.
CRC, CPC, CCS-P or equivalent preferred.

Responsibilities

Oversee encounter data pipeline integrity and end-to-end submission processes.
Track federal response files (999, 277CA, MAO-002) and RAPS, monitor for accuracy.
Lead root-cause analyses on rejected encounters and implement corrective actions.
Govern data ingestion from delegated IPAs and enforce data transmission SLAs.
Scrub and correct front-end/rejection issues to protect risk scores.
Generate data-gap reports for Provider Relations and address billing errors.
Develop monthly reconciliation dashboards tracing codes from chart to CMS acceptance.
Lead CMS RADV audits and document validation trails.

Skills

Advanced Excel

Data analysis

Leadership

Stakeholder management

Problem solving

Communication

Attention to detail

Education

Bachelor’s degree in business, public health, healthcare administration, informatics, or related field

Master’s degree in related field (preferred)

CRC, CPC, CCS-P or equivalent coding credential (preferred)

Tools

EDI (837P/837I)

RAPS/EDPS

Clearinghouse systems

Job description

Overview

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 anauthentic 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.

Additional Benefits

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

Key Responsibilities

Encounter Data Pipeline Oversight & Integrity:
End-to-End Submission Management: Manage daily technical and operational data streams for all risk adjustment submissions, ensuring seamless transaction flows from internal claims systems through 837P/837I EDI layouts into RAPS and EDPS (or state Medicaid systems)
Response File Tracking: Systematically ingest, track, and monitor daily and weekly federal response files, specifically monitoring the 999 (functional acknowledgment), 277CA (claim acknowledgment), MAO-002 (Encounter Data Processing Status), and RAPS return files
Error Diagnosis & Resolution: Lead technical root-cause analyses on rejected encounters. Develop and execute tactical corrective action plans to correct structural EDI loop errors, demographic mismatches, and invalid National Provider Identifiers (NPIs)
Multi-Network Reconciliation Strategy (FFS vs. Delegated IPAs):
Delegated IPA Governance: Govern the data-ingestion pipelines from delegated IPAs. Establish strict encounter submission schedules, audit their inbound encounter completeness, and enforce data transmission SLAs
Independent FFS Rejection Scrubbing: Monitor claims from independent community clinics. Build internal operational sweeps to quickly identify valid clinical codes that were rejected at the front-end or clearinghouse level, manually or systematically correcting them to protect the plan's risk score
Provider-Level Reconciliation: Generate data-gap reports for internal Provider Relations teams to address systemic, clinic-level billing errors (e.g., outdated electronic billing setups at independent clinics that cause continuous data dropouts)
Audit Support & Regulatory Compliance:
Data Reconciliation Loops: Build and maintain monthly, end-to-end reconciliation dashboards that visually trace a medical code from the initial provider chart/encounter, through claims processing, to final CMS acceptance, ensuring zero technical data leaks
Risk Adjustment Data Validation (RADV) & Compliance Audit Support: Act as the technical data lead during CMS RADV audits or OIG inquiries. Produce transaction trails and data-validation logs proving that submitted codes align with accepted regulatory files
Deletion Management: Oversee the critical compliance process of submitting delete records for unconfirmed or un-vouched HCC codes, protecting the health plan from regulatory overpayment liabilities
Cross-Functional Technical Alignment:
IT & Claims Operations Integration: Serve as the primary risk adjustment liaison to internal IT, Core Claims Ingestion, and EDI clearinghouse teams to optimize system mappings during annual CMS code updates (ICD-10 revisions) or system migrations
Prospective Program Feedback Loop: Partner with the Prospective Risk Adjustment team to track encounter submissions generated from In-Home Assessments (IHAs) or point-of-care vendor campaigns, ensuring these high-value data captures successfully bypass front-end rejections
Team Leadership: Provide leadership, coaching, and guidance to the team to ensure high performance, accountability, and engagement. Support employee development, reinforce operational standards, and create a collaborative environment that aligns with departmental and organizational goals. Hire, train, and manage support staff, while monitoring and evaluating outcomes. Conduct performance reviews of each Team Member within IEHP guidelines
Governance, Reporting & Continuous Improvement:
Governance & Reporting: Maintain SOPs, workflow documents, and control checklists supporting audit readiness and risk adjustment compliance
Continuous Improvement: Develop process improvements to reduce rejections, increase submission success rates, and enhance transparency into encounter flows
Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

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