Note: The job is a remote job and is open to candidates in USA. CVS Health is dedicated to building a world of health around every individual, emphasizing a connected and compassionate health experience. The Manager, Encounter Data & State Submission Operations will lead the management of encounter and claims data submissions, ensuring compliance with state regulations and operational requirements while collaborating with various internal and external teams.
Responsibilities
- Serve as the subject matter expert for state-specific encounter data submission requirements and maintain comprehensive documentation of all applicable regulations and processes
- Lead the end-to-end management of encounter submissions, ensuring compliance with state and regulatory requirements
- Partner with technical teams and vendors to implement, monitor, and maintain processes that support accurate encounter data reporting and submissions
- Oversee 837 file transmission processes, ensuring files are submitted accurately, timely, and in accordance with state specifications
- Manage state response files, reconciliation activities, and error reporting to ensure all submitted transactions are accounted for and resolved
- Establish and maintain reporting, monitoring, and tracking processes for encounter submission performance, acceptance rates, and error trends
- Drive root cause analysis and coordinate corrective actions to resolve encounter submission errors and improve data quality
- Develop, document, and enhance operational processes related to encounter data management and state reporting
- Collaborate with cross-functional teams including Claims, IT, Compliance, Operations, Risk Adjustment, and vendor partners to ensure alignment and successful execution of encounter submission objectives
- Support audits, regulatory reviews, and internal compliance initiatives related to encounter data submissions
- Monitor changes in state and federal requirements and lead implementation efforts to maintain ongoing compliance
Skills
- Minimum of 5 years of experience in healthcare claims operations, including medical claims processing and/or Medicare and Medicaid lines of business
- At least 2 years of experience overseeing secure data transmission processes utilizing SFTP and other file transfer technologies, with responsibility for monitoring, troubleshooting, and ensuring data integrity
- 3+ years of experience in data management, including data validation, reconciliation, reporting, and issue resolution
- 3+ years of leadership experience with demonstrated success managing workflows and leading, developing, and supporting teams within a healthcare operations environment
- 2+ years experience working with states on DSNP encounter submissions
- 2+ years experience working with the state of Florida on encounter submissions
- 2+ years experience with vendor management
- Candidates located on the East Coast are strongly preferred
Benefits
- This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
- This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
- The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
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