Senior Encounter Data Specialist

Delta Dental Plan of Michigan, Inc.; Okemos (MI); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Delta Dental Plan of Michigan, Inc. in Okemos, MI is seeking a Senior Encounter Data Specialist to lead analysis, correction, and recommendations on encounter data issues. The role will ensure compliance with internal guidelines and external processing standards.

You will oversee audits, EDI/X12 exchanges, data integrity, and cross‑functional onboarding activities, while maintaining strong stakeholder relationships and adherence to HIPAA requirements.

Qualifications

• Bachelor's degree in business administration or related field.
• Seven years of experience identifying, analyzing, or resolving business, system, or process issues in health plan benefits administration, including encounter data processing.
• Experience with Medicare/Medicaid regulations and HIPAA guidance is preferred.

Responsibilities

• Represents the encounter team to leadership with reports, project progress, metrics, and updates.
• Leads correction of rejected encounters by researching and ensuring compliance with guidelines.
• Monitors and audits encounter submissions for timely and accurate processing.
• Leads onboarding activities for new customers and cross-functional coordination.
• Serves as SME during audits and coordinates materials and responses.
• Oversees EDI and X12 data exchange compliance with HIPAA and partner mandates.
• Manages policies, error libraries, and reporting tools for daily/weekly oversight.
• Coordinates data maintenance for eligibility, providers, and benefits records.
• Performs root cause analysis to prevent recurrence of issues.
• Builds relationships with internal/external plans and stakeholders.

Skills

EDI formats

Data analysis

Cross-functional leadership

Auditing

Regulatory compliance

Communication skills

Microsoft Office

Education

Bachelor's degree in business administration or related field

Tools

Microsoft Excel

ERP/healthplan systems

Job description

Job Title: Senior Encounter Data Specialist

Number of Positions: 1

Location: Okemos, MI

Location Specifics: Hybrid Position

Job Summary:

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation. At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do - from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description:

Leads the organization, analysis, correction and recommendation of solutions to internal and external stakeholders regarding encounter data issues, policies, processes, requirements, and records.

Primary Job Responsibilities:

• Represents the encounter team to leadership by presenting reports, project progress, metrics, deliverables, and other encounter-related updates.
• Leads and oversees the correction of rejected encounters by researching, reviewing, and interpreting encounter data, identifying potential issues, and ensuring corrections comply with internal and external processing guidelines and best practices.
• Monitors, manages, and audits encounter submissions to ensure timely, accurate file submission and processing.
• Leads encounter implementation activities for new customer onboarding, driving cross-functional coordination and ensuring deliverables align with internal standards, regulatory expectations, and external customer requirements.
• Serves as a key subject matter expert during internal and external audits by coordinating requested materials, completing audit responses, preparing supporting documentation, presenting findings, and monitoring audit-related reports to demonstrate compliance with audit requirements.
• Provides oversight of electronic data interchange (EDI) and X12 data exchange compliance, ensuring encounter transactions adhere to applicable industry regulations, HIPAA requirements, and partner-specific mandates.
• Monitors the development, implementation, maintenance, and application of encounter policies, procedures, error libraries, and reporting tools to correct rejected encounters and support daily and weekly operational oversight.
• Monitors and evaluates related processes to ensure internal and external requirements are met, represents the encounter team when partnering with functional areas to maintain claims system support tables, and coordinates data entry or general data maintenance for eligibility, providers, fee sets, benefits and related records.
• Oversees root cause analysis for encounter errors and reviews results, processes, and/or system programming with other departments to minimize repeat issues, identify opportunities for improvement, and recommend solutions.
• Establishes and maintains strong relationships with internal and external plans, partners, and other stakeholders to correct, prevent, and resolve encounter errors.
• Serves as lead subject matter expert and key internal consultant on encounter data, policies, processes, compliance, and corrections, develops training for internal stakeholders regarding regulatory changes, and coordinates and leads encounter data and compliance meetings.
• Oversees compliance with data integrity policies for all system configurations.
• Leads the recruitment process for new encounter data staff, including interviewing, selection, onboarding and training.
• Assures adherence to company policies, internal controls, regulatory compliance, and general principles.
• Communicates and manages encounter deliverables to ensure compliance with state requirements and contract SLAs.
• Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Hybrid

Minimum Requirements:

Position requires a bachelor’s degree in business administration or a related field and seven years of experience identifying, analyzing, or resolving business, system, or process issues in the administration of health plan benefits, including experience with encounter data processing. Experience administering Medicare and/or Medicaid programs and applying Centers for Medicare and Medicaid Services regulations and guidelines is preferred. Will accept any suitable combination of education, training, or experience. Position requires experience with EDI formats, database applications, analytical reporting tools, and Microsoft Office applications; strong verbal and written communication skills; strong analytical skills; ability to lead cross-functional work; the ability to manage multiple assignments with competing deadlines; strong interpersonal skills, including the ability to represent and present to organizational leadership; and the ability to identify and resolve complex problems using independent judgement.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.

Delta Dental of Michigan, Ohio, and Indiana has been a dental benefits leader for more than 60 years, and today with our affiliates, we are one of the largest dental plan administrators in the country. It’s our mission to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by making investments that build healthy, smart, vibrant communities. We celebrate diverse thought and foster a culture where employees go All In - for the company, themselves, their colleagues and their communities.

Employees are offered a comprehensive benefits package that includes medical, dental and vision coverage, short- and long-term disability, life insurance, 401(k) savings plans, flexible spending accounts, and tuition reimbursement or educational assistance.

Employees are also eligible for annual incentive compensation based on annual business goals.

Additionally, employees receive eight hours of paid volunteer time each year, access to an on-staff health coach and personal trainer, plus many other perks.

Delta Dental is an Equal Opportunity Employer.