Job Description:

• lead end-to-end encounter submission processes, ensuring compliance with CMS and state Medicaid guidelines
• monitor, analyze, and resolve encounter submission errors using automated workflows and root cause analysis
• ensure accuracy, completeness, and timeliness of encounter data submissions to maximize acceptance rates and minimize rejections
• configure and validate Facets components across claims, benefits, pricing, and rules to ensure proper adjudication outcomes
• align encounter data processes with claims adjudication logic, 837/835 transaction flows, and EDI processing
• troubleshoot configuration and data issues impacting claims processing, encounters, and regulatory submissions
• validate and reconcile data across multiple systems to ensure accurate encounter submissions and minimize financial risk
• identify data gaps, mismatches, or revenue leakage risks related to Medicare Advantage and Medicaid
• implement improvements to increase encounter acceptance rates and reduce resubmissions
• support testing cycles (UAT, regression, validation) for new configurations or system enhancements

Requirements:

• 5+ years of healthcare payer experience (Medicare and Medicaid)
• 5+ years of hands-on experience with Facets (TriZetto) and EDM across claims and configuration modules
• strong experience with: 837/835 transactions and EDI processing
• encounter data submissions and reconciliation
• working knowledge of claims payment systems
• claims adjudication processes
• experience working in consulting or client-facing environments
• ability to communicate with technical and non-technical staff

Benefits:

• medical, dental, and vision coverage to employees and dependents
• a 401(k) plan with a generous employer match
• an employee stock purchase plan
• a generous Paid Time Off policy
• paid parental leave and adoption assistance
• wellness program supporting employee total well-being

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