Evolent Health Manager, Medicaid Encounter/Claims Reporting in Chicago, Illinois

It’s Time For A Change…Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

This position manages the day to day operations of the Evolent Health Encounters department as well as encounter submissions. Accountabilities include but are not limited to guiding the delivery of departmental/organizational objectives and goals in accordance with current applicable federal, state, and health plan standards.

Responsibilities

  • Manages the process for encounter generation and submission by Third Party Administrators (TPAs).

  • Keeps abreast of changes in CMS and DMS encounter submission requirements, including penalties for failure to meet these requirements.

  • Communicates changes in Electronic Data Interchange (EDI) requirements, SNIP edits, and DMS threshold edits to all TPAs.

  • Manages the Encounter Department staff as they serve as technical advisors to TPAs for the generation of EDI 837 transaction files and the analysis of 277U and 999 response files. Guides and assist teams to resolve complex issues.

  • Oversees encounter activities of all Third Party Administrators.

  • Monitors the performance of TPAs to insure they exceed encounter related service level agreements.

  • Maintains documentation to support penalties that may be assessed to TPAs for failure to meet service level agreements or CMS/DMS requirements.

  • Partners with the TPAs to improve processes by developing edits and business rules that meet the requirements of CMS and DMS for the proper submission of encounters.

  • Manages data warehouse of encounter transactions that documents the status of each transaction.

  • Acts as a process improvement champion.

  • Plan and develop procedures to improve the operating quality and efficiency of the department.

  • Engages leadership and stakeholders to obtain support and buy in for changes.

  • Partners with management, project champions, and process owners to align process improvement initiatives with business objectives.

  • Shares accountability for realization of results with process owners and may present recommendations to stakeholders and process owners.

  • Acts in a leadership role in managing the Encounters Department.

  • Manage the operational and fiscal activities of the department to include: staffing levels, budgets, and financial goals.

  • Leads team in a manner conducive to ongoing growth and expanded knowledge of associates.

  • Coaches team members in the use of data and appropriate analytical tools that support improved quality.

  • Supports team members in the identification and creative problem resolution for improved processes and expanded use of technology.

  • Supports collaborative team efforts that produce effective working relationships and trust.

  • Leads by example in producing work that is timely and of high integrity.

  • Displays willingness to work with staff to promote staff development to full potential.

  • Systematically keeps staff informed of policy and procedural changes affecting program and administrative operations.

  • Regularly suggests innovative means of structuring operations in a fashion that helps alleviate backlogs and ensures the optimal utilization of resources.

  • Perform other duties and projects as assigned.

The Experience You Need (Required):

  • Bachelor’s degree required in Information Technology, Accounting, Business or related field.

  • Minimum 8-10 years of experience in health insurance, managed care, or healthcare provider environment with a focus on information technology, electronic data interchange, and claims transactions.

  • 5 years vendor/subcontractor management experience preferred.

  • 3-5 years overseeing a Management Information System or Data Warehouse.

  • Strong working knowledge of relational databases and SQL.

  • 2-4 years of management experience in a comparable position.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.