Manager, Business Consultant
Core
Lead end-to-end management of encounter and claims data submissions to state agencies, ensuring accuracy, completeness, and regulatory compliance for Dual Special Needs Plans.
Role type
Manager, Healthcare Claims Operations & State Submission
Builds
Accurate encounter data reporting and state submission processes for DSNP
Domain
Healthcare / Insurance / Claims Processing
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure
Required skills
Healthcare claims processing, Medicare/Medicaid operations, 837 claims transaction standard, state-specific submission requirements, secure data transmission (SFTP), data validation and reconciliation, root cause analysis, vendor management, regulatory compliance monitoring
Preferred skills
DSNP encounter submissions, Florida state encounter submissions, East Coast location
Technologies
SFTP, 837 file format
Responsibilities
Serve as subject matter expert for state-specific encounter data submission requirements; Lead end-to-end management of encounter submissions ensuring compliance; Partner with technical teams and vendors to implement and monitor data reporting processes; Oversee 837 file transmission processes; Manage state response files, reconciliation, and error reporting; Establish monitoring processes for submission performance and error trends; Drive root cause analysis for submission errors; Collaborate with cross-functional teams including Claims, IT, Compliance, and Risk Adjustment; Support audits and regulatory reviews; Monitor changes in state and federal requirements and lead implementation efforts.
Seniority
Manager, hands-on leadership
