Senior Encounter Data & Coding Specialist

Elders; Oakland (CA); On-site; USD 96,000 - 145,000; Full time

Job summary

Center for Elders' Independence seeks a Senior Encounter Data & Coding Specialist to ensure completeness, accuracy, and regulatory compliance of encounter data, ICD-10-CM coding, and clinical documentation for CMS, Medicare, Medicaid, and PACE reporting.

This senior professional collaborates with clinicians, HIM, and IT to resolve discrepancies, support revenue integrity and risk adjustment, and maintain dashboards while preparing leadership reports.

Qualifications

• Bachelor's degree preferred in a related field.
• Minimum five years healthcare experience spanning encounter data, medical coding, revenue cycle, risk adjustment, or Health Information Management.
• Minimum three years of experience with PACE, Medicare Advantage, managed care, risk adjustment, or encounter data; direct PACE experience preferred.
• Experience investigating encounter submission errors and performing reconciliation activities.
• Certifications preferred (CPC, CRC, CCS, RHIT, RHIA); CPC/CRC strongly preferred.
• Knowledge of ICD-10-CM coding guidelines and Medicare risk-adjustment methodologies.
• Proficiency with Excel, SQL, Power BI, and healthcare analytics tools.

Responsibilities

• Review, validate, monitor, and reconcile encounter data submissions.
• Investigate rejections, edits, denials, and discrepancies.
• Correct and resubmit encounter records as needed.
• Perform reconciliation between EHRs, billing, claims, and CMS reports.
• Develop data quality controls and conduct coding reviews.
• Assign and validate ICD-10-CM codes based on documentation.
• Identify documentation deficiencies and initiate provider queries.
• Collaborate with clinical staff to improve documentation quality.
• Prepare reports for Revenue Cycle, Finance, Compliance, and Leadership.

Skills

Analytical

Attention to detail

Regulatory compliance

Communication skills

Education

Bachelor's degree (Health Information Management, Healthcare Administration, Nursing, Business Administration, or related)

Tools

Microsoft Excel (Advanced)

SQL

Power BI

Healthcare analytics tools

Job description

Senior Encounter Data & Coding Specialist

The Center for Elders' Independence is a PACE (Program of All-Inclusive Care for the elderly) organization that uses an interdisciplinary team approach to care planning and care implementation for the purpose of providing high quality, affordable, integrated health care services to the elderly, including an Adult Day Health Center, and promoting autonomy, quality of life and the ability of individuals to live in their communities.

The Position: The Senior Encounter Data & Coding Specialist ensures completeness, accuracy, and regulatory compliance of encounter data, diagnosis coding, and support clinical documentation for CMS, Medicare, Medicaid, and PACE reporting. This senior individual-contributor role combines encounter oversight, coding validation, error resolution, reconciliation, concurrent and retrospective coding review, and clinical documentation improvement.

The Specialist collaborates closely with clinical staff, providers, Health Information Management (HIM), and Information Technology teams to identify and resolve encounter and coding discrepancies while supporting revenue integrity, risk adjustment, and regulatory compliance.

The annual pay range for the Senior Encounter Data & Coding Specialist position at Center for Elders' Independence is $95,721 to $145,496. Placement within the range is determined based on job-related factors such as relevant experience, skills, abilities, internal equity, and market data, consistent with CEI's annual compensation review and established compensation practices

DUTIES AND RESPONSIBLITIES:

• Review, validate, monitor, and reconcile encounter data submissions.
• Investigate encounter rejections, edits, denials, and discrepancies.
• Correct and resubmit encounter records, as necessary.
• Perform encounter reconciliation between electronic health records, billing systems, claims systems, and CMS submission reports.
• Monitor encounter acceptance, rejection, and resubmission rates; identify trends affecting submission timeliness and accuracy; and elevate material issues with recommended corrective actions.
• Develop and maintain encounter data quality controls.
• Conduct concurrent and retrospective coding reviews of participant records.
• Assign and validate ICD-10-CM diagnosis codes based on clinical documentation.
• Verify appropriate capture of chronic conditions and risk-adjusting diagnoses.
• Review documentation to ensure coding compliance and accuracy.
• Identify documentation deficiencies and initiate provider queries as appropriate.
• Collaborate with providers and clinical staff to improve documentation quality.
• Serve as the primary resource for encounter error investigation and resolution.
• Analyze CMS submission reports and identify root causes of recurring errors.
• Create corrective action plans for encounter and coding issues.
• Maintain dashboards and reports related to encounter performance metrics.
• Prepare reports for Revenue Cycle, Finance, Compliance, and Executive Leadership.
• Support accurate capture of Medicare risk adjustment diagnoses.
• Validate documentation supporting HCC conditions.
• Partner with clinical teams to ensure complete annual diagnosis capture.
• Participate in chart reviews and coding audits related to risk adjustment activities.
• Ensure compliance with CMS, Medicare, Medicaid, and PACE regulations.
• Support internal and external audits.
• Assist in the development of policies and procedures related to encounter data and coding.
• Maintain documentation supporting audit readiness.
• Work closely with: Physicians, Nurse Practitioners, IT.
• Provide education and feedback regarding coding, documentation, and encounter requirements.

QUALIFICATIONS:

• Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, Business Administration, or related field preferred.
• Minimum five years of healthcare experience spanning encounter data, medical coding, revenue cycle, risk adjustment, or Health Information Management, including progressively responsible work in data validation, coding review, reconciliation, or regulatory reporting.
• Minimum three years of experience with PACE, Medicare Advantage, managed care, risk adjustment, or encounter data; direct PACE experience preferred.
• Experience investigating encounter submission errors and performing reconciliation activities.
• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) preferred; CPC or CRC strongly preferred. Equivalent proven ability in ICD-10-CM coding, risk adjustment, and encounter-data validation may be considered.
• Demonstrated knowledge of ICD-10-CM coding guidelines.
• Must demonstrate knowledge of Medicare risk-adjustment methodologies, CMS Encounter Data System requirements and reports, Electronic Health Records, revenue-cycle workflows, claims and encounter processing, and applicable CMS regulatory requirements, including diagnosis submission through EDS.
• Technical skills preferred Microsoft Excel (advanced level), SQL, Power BI, Healthcare analytics tools.
• Must have excellent analytical, organizational, and problem-solving skills.
• Analytical problem-solving, Attention to detail, Data reconciliation, Coding accuracy, Regulatory compliance, Relationship building,
• Strong written and verbal communication skills.

The above job description is intended to communicate the general function of the mentioned position and by no means shall be considered an exhaustive or complete outline of the specific tasks and functions that will be required. CEI reserves the right to change job descriptions, site assignments, and or work hours as required by the needs of the program. All employees are expected to perform their duties within their ability as required by the job and/or as requested by management.