Senior Risk Adjustment Data Reconciliation Lead

Inland Empire Health Plan; Rancho Cucamonga (CA); Hybrid; USD 119,000 - 157,000; Full time

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

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