The Manager, Clinical Data Management is responsible for the full lifecycle of our Encounter Data Submission and Reconciliation strategy, ensuring that diagnoses are accurately tracked, submitted, and accepted by payers and CMS. In this role, you’ll lead the operational and strategic work that turns clinical documentation into reliable, compliant, and financially meaningful data. You’ll collaborate across internal teams, vendors, and payers to spot gaps early, solve root causes, and continuously improve how we submit and reconcile encounter data. If you thrive at the intersection of healthcare data, process ownership, and cross-functional leadership, this role offers the chance to make a measurable difference.
- Primary Duties
- Data Submission & Reconciliation Process
Oversee end-to-end strategy, priorities, and operations for accurate and compliant encounter data submission to payers and CMS.
Create and transmit ASM files on established cadences, maintaining payer-specific templates and submission methods annually.
Establish routine reconciliation processes to track diagnoses from documentation to acceptance, quantifying gaps and identifying dropped/truncated records early.
Lead root-cause analysis and corrective action across internal teams, vendors, and payers for rejected or dropped diagnoses.
Partner with operations leadership to drive strategy, chart selection, and annual evaluation for the retrospective chart review initiative.
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Compliance & Quality Assurance
Monitor submission metrics and acceptance rates, applying data scrubs and business rules to meet regulatory standards and CMS/payer deadlines.
Collaborate with leadership and legal partners to ensure full compliance regarding add and delete diagnosis workflows.
Develop and maintain process documentation, SOPs, and routine workflow updates.
Process Improvement
Identify tools and long-term strategies to improve encounter acceptance rates, minimize manual effort, and expand ASM processes across eligible payers.
Evaluate annual ROI across submission and audit processes, optimizing workflows to drive financial performance.
Cross-Functional Collaboration
Lead cross-functional initiatives with key stakeholders to resolve data flow issues and implement system updates.
Integrate accepted ASM submitted diagnosis data into existing risk reporting dashboards and build new recurring reports for leadership
Own ASM valuation and financial results, partnering with Data and Analytics on metric definitions and data quality
- Other duties as assigned
- Minimum Qualifications
- Bachelor’s degree in Business, Finance, IT, Healthcare Analytics, or Operations
6+ years of experience with Medicare Advantage or ACA encounter data processes, and/or risk adjustment experience within a payer, vendor, or Value Based Care organization
3+ years of program or project management experience, including ownership of complex, multi-stakeholder initiatives
2+ years of working knowledge with X12 837 transaction sets; Working knowledge of CMS EDPS experience (MAO-002/MAO-004 reports)
Strong analytical capabilities with a demonstrated ability to interpret complex datasets and synthesize actionable insights
Excellent written and verbal communication skills, with proven experience developing and presenting key information to executive leadership
Working knowledge of SQL, including writing, modifying, and executing queries
- Proficiency in Google Workspace, project tracking software (i.e. Jira, Smartsheet), and business intelligence or dashboard platforms
- Preferred Qualifications
- Familiarity with Business Process Reengineering (BPR) principles and methodologies to optimize processes for enhanced efficiency and performance
Experience with chart selection or targeting strategies for retrospective chart review
- Fundamental understanding of relational databases
- Physical Requirements
- Prolonged periods of sitting at a desk and working on a computer
