Manager, Risk Adjustment Encounter Data Reconciliation

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 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.

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 t