Associate Director Encounters

Associate Director - Encounters

Job Summary

We are seeking an experienced Associate Director – Encounters to lead and oversee encounter data management, regulatory compliance, and operational efficiencies in the healthcare payer space. This role is critical in ensuring accurate submission, reconciliation, and compliance of encounter data with CMS, Medicaid, and other regulatory agencies. The ideal candidate will have deep expertise in encounter processing, regulatory reporting, payer operations, and healthcare data management.

Key Responsibilities

Encounter Data Management & Compliance:

• Oversee end-to-end encounter data submission, reconciliation, and error resolution for Medicare, Medicaid, and commercial health plans.
• Ensure compliance with CMS, state Medicaid agencies, NCQA, HIPAA, and risk adjustment requirements.
• Develop and implement data validation, auditing, and quality assurance processes.
• Work with internal and external stakeholders to resolve encounter submission rejections, errors, and discrepancies.

Operational Leadership & Process Improvement:

• Lead a team of encounter analysts and specialists to improve operational efficiencies.
• Drive automation and enhancements in encounter data workflows, reporting, and reconciliation processes.
• Collaborate with IT, data analytics, and compliance teams to implement EDI, FHIR, and API-based solutions for encounter processing.
• Monitor and report on key performance indicators (KPIs) related to encounter data accuracy, timeliness, and compliance.

Cross-Functional Collaboration & Stakeholder Management:

• Partner with internal payer operations, claims, provider data management, and finance teams to ensure alignment of encounter data with claims processing and reimbursement models.
• Work closely with state and federal regulators, health plan executives, and vendors to enhance submission processes and regulatory adherence.
• Act as a subject matter expert (SME) for encounter reporting, regulatory updates, and payer industry best practices.

Technology & Data Analytics:

• Support system upgrades, data warehouse integration, and business intelligence (BI) initiatives to optimize encounter data management.
• Utilize SQL, Power BI, Tableau, or other analytics tools to track encounter submission trends, error rates, and compliance risks.
• Ensure alignment with Electronic Data Interchange (EDI) standards, including 837 encounter transactions.

Qualifications & Requirements

Education & Experience:

• Bachelor’s degree in healthcare administration, Business, Information Systems, or a related field (master’s preferred).
• 8+ years of experience in healthcare payer operations, with a focus on encounter data management, claims processing, and regulatory compliance.
• 3+ years in a leadership role managing encounter data teams and enterprise-wide reporting functions.

Skills & Competencies:

• Strong understanding of Medicaid/Medicare encounter data submission requirements and regulatory reporting.
• Experience with EDI transactions (837I, 837P, 277CA, 999), CMS/State Medicaid reporting, and data reconciliation processes.
• Knowledge of risk adjustment models, capitated payment structures, and value-based care frameworks.
• Expertise in healthcare data analytics, SQL, data warehousing, and BI reporting tools.
• Excellent problem-solving, leadership, and stakeholder engagement skills.

Preferred Qualifications:

• Experience with healthcare payer platforms (Facets, QNXT, HealthEdge, or similar systems).
• PMP, Six Sigma, or SAFe Agile certification.
• Familiarity with HEDIS, STAR ratings, and encounter-based quality reporting.