- 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.
- 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.
- Analytical
- Detailed
- Negotiator
- Responsible/Accountable
- Problem solver
- Must be able to access and navigate each department at the organization's facilities.
- Sedentary work that primarily involves sitting/standing.
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Medicaid Encounter Program Manager - San Juan, Puerto Rico - abarca health
Descripción
What you'll do
In a few words...
Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning...
Providing high quality services to client and beneficiaries is at the core of what we do every day The PBM Operations & Services team is the very heart of Abarca and meets that standard by running services from medication therapy management to price eligibility to government services and beyond.
As our Encounter Data Program Manager, you will oversee the accurate management, transfer, and audit of encounter data, related contractual requirements, monitoring encounter submissions and rejections, among other areas. You'll 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 As our SME in that role, you'll be able to translate regulatory guidance into matching business processes and accurate system requirements for our operations and technical team. We need your analytical mindset and keen eye to provide oversight and analysis as well as determine improvements for our process while we meet service level agreements with state regulators and Centers for Medicaid and Medicare Services.
The fundamentals for the job...
What you're made of
The bold requirements...
That something extra we ́d love to see...
Physical requirements...
