Healthcare Encounter Data Operations Lead

hace 1 mes


San Juan, San Juan, Puerto Rico abarca health A tiempo completo
About Abarca Health

Abarca Health is revolutionizing pharmacy benefits with smarter technology, but this is just the beginning...

At Abarca, providing high-quality services to clients and beneficiaries is at the core of what we do every day. Our PBM Operations & Services team meets this standard by running services from medication therapy management to price eligibility to government services and beyond.

Job Description

We are seeking an experienced Healthcare Encounter Data Operations Lead to oversee the accurate management, transfer, and audit of encounter data, related contractual requirements, monitoring encounter submissions and rejections, among other areas.

The ideal candidate will be our key subject matter expert on all business processes and systems requirements related to monitoring, submitting, and discussing encounter data submission with Federal and State regulators.

You will translate regulatory guidance into matching business processes and accurate system requirements for our operations and technical team.

This role requires a strong analytical mindset and keen eye to provide oversight and analysis as well as determine improvements for our process while meeting service level agreements with state regulators and Centers for Medicaid and Medicare Services.

Main Responsibilities:
  • Engage directly with internal teams, clients, and auditors as our subject matter expert in Medicaid Encounter Data processes through providing guidance as a strategic consultant.
  • Assess regulatory guidance and technical specifications to build or guide processes that develop key performance indicators and ensure Encounter Data accuracy.
  • Establish effective oversight and monitoring programs to ensure all client and Center for Medicare and Medicaid Services (CMS) requirements are met.
  • Collaborate with internal teams on client implementations, facilitating discussions that directly impact encounter data submissions, detailed process documentation, internal training programs, corrective action implementations, adhoc analysis, request for proposal responses, presentations, and other support items as needed.
  • Assess adjudication, logics, and claims reprocessing enhancement and improvements to determine Encounter Data implications, remediation, and monitoring the efficacy of corrective actions.
  • Collaborate with the client implementation team in the Encounter Data process requirements gathering, configuration, E2E testing, and go-live process.
Requirements:
  • Bachelor's Degree (In lieu of a degree, equivalent relevant work experience may be considered.)
  • 3+ years of experience with pharmacy benefit management and/or with Medicaid claims management.
  • 2+ years of experience working directly with Encounter Data accuracy and resolving Encounter Data errors.
  • Experience in defining and communicating business requirements with both technical and non-technical audiences.
  • Knowledge in Encounter Data submissions, rejections, processes, and requirements.
  • Ability to identify challenges, ideate creative solutions, and lead implementation of changes.
  • Ability to organize and lead cross-functional team projects and initiatives.
  • Highly organized and adaptable, able to work in a fast-paced environment.
Estimated Salary: $80,000 - $110,000 per year
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