Manager, Risk Adjustment, Encounter Data Reconciliation

IEHP

. Manage daily technical and operational data streams for risk adjustment submissions from internal claims systems through 837P/837I EDI layouts into RAPS, EDPS, or state Medicaid systems .

Posted 10/9/2026full-timeRancho Cucamonga • California • United StatesMid-LevelSenior💰 $118,602 - $157,144 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates advanced knowledge of healthcare EDI transactions, including EDI 837P/837I and CMS response reporting mechanisms, while effectively managing encounter data reconciliation and leading teams to improve submission success rates.

Highest-signal resume keywords

Healthcare EDI Data ManagementEncounter Data ReconciliationCMS Response Reporting MechanismsLeadership ExperienceAdvanced Microsoft Excel Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

EDI 837P/837IRAPS ProcessingData ValidationData AnalysisFile Layout ProcessingData Transmission SLAsRejection-ScrubbingRoot-Cause AnalysisProcess ImprovementData-Gap Reporting

Soft Skills

Interpersonal SkillsDetail OrientedProblem SolvingCommunicationTeam Leadership

Tools & Technologies

Microsoft ExcelPower QueryClearinghouse ProcessesCMS SystemsState Medicaid Systems

Certifications & Qualifications

CRCCPCCCS-P

Industry Keywords

Managed CareHealth Plan OperationsRisk AdjustmentEncounter DataHealthcare Administration

About the role

Key responsibilities & impact

Manage daily technical and operational data streams for risk adjustment submissions from internal claims systems through 837P/837I EDI layouts into RAPS, EDPS, or state Medicaid systems
Track and monitor federal response files, including 999, 277CA, MAO-002, and RAPS return files
Lead root-cause analyses and corrective action plans for rejected encounters, including EDI loop errors, demographic mismatches, and invalid NPIs
Govern delegated IPA data-ingestion pipelines, encounter submission schedules, completeness audits, and data transmission SLAs
Monitor independent community clinic claims and conduct rejection-scrubbing sweeps to correct valid clinical codes
Generate provider-level data-gap reports for Provider Relations teams
Build and maintain monthly end-to-end reconciliation dashboards tracing encounters through CMS acceptance
Support CMS RADV audits and OIG inquiries by producing transaction trails and data-validation logs
Oversee deletion of unconfirmed or un-vouched HCC records
Liaise with IT, Core Claims Ingestion, and EDI clearinghouse teams on mappings, ICD-10 updates, and system migrations
Partner with Prospective Risk Adjustment teams to validate submissions from In-Home Assessments and point-of-care campaigns
Lead, coach, hire, train, manage, and evaluate support staff
Maintain SOPs, workflow documents, and control checklists for audit readiness
Develop process improvements to reduce rejections and increase submission success rates
Perform other duties required to support health plan operations and departmental needs

Requirements

What you’ll need

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
Master’s degree in business, public health, healthcare administration, informatics, or a related field preferred
CRC, CPC, CCS‑P, or equivalent coding credential preferred
Must have a valid California Driver’s license
Advanced knowledge of CMS response reporting mechanisms, specifically MAO-002, MAO-004, and monthly RAPS error summaries
Knowledge of state-specific Medicaid encounter data processing models is a plus
Experience with EDI 837P/837I, 835 remits, and clearinghouse processes
Knowledge of the risk adjustment data lifecycle from clinical documentation through CMS acceptance
Advanced technical proficiency with healthcare EDI transactions, processing file layouts, and executing data sweeps
Expert-level Microsoft Excel capability, including nested logic functions, complex pivot tables, and Power Query, is mandatory
Proven ability to analyze dense log files or data anomalies, isolate systemic errors, and partner with programmers/IT to implement automated fixes
Strong interpersonal skills to translate technical data extraction errors into actionable operational requests
Ability to be detail oriented, communicate with diplomacy, lead staff, manage competing priorities, build relationships, and identify and resolve problems

Benefits

Comp & perks

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
Monday and Friday remote work schedule
Local travel to providers as needed