Encounter Data Specialist

US-CA-Los Angeles
Job ID
Managed Care


The Encounter Data Specialist is responsible for managing all aspects of encounter data through all contracted health plans that supports AltaMed’s managed care initiatives. This position manages encounter data submissions through methodical investigation, analysis, review and documentation of multiple levels of requirements from an end-to-end perspective and supports the ongoing management of the requirements. This position will assist in report creation and audit/reconcile health plan encounter data submissions. It is responsible in communicating and coordinating with IT, PFS, clearinghouses and contracted health plans on encounter related efforts. Encounter Data Specialist will also coordinate and manage the implementation and/or integration of products and support of the encounter inbound and outbound functions. The Encounter Data Specialist will maintain knowledge of all HIPAA EDI protocols, X12 transaction sets and other EDI processing standards.



  1. Monitor and support all EDI processes, including troubleshooting EDI production issues and working with IT and health plans to identify solutions and resolve all issues effectively.
  2. Identify and resolve health plan rejections daily along with managing all communication with clearinghouses and health plans.
  3. Review transaction acknowledgements/responses and coordinate remediation efforts with internal customers and external EDI trading partners.
  4. Analyze routine EDI processes and develop weekly and/or monthly activity reports as well as audit reports for management to facilitate performance and process improvement.
  5. Monitor encounter data volumes quarterly (by FQHC and IPA) by line of business and send warning letters to providers with deficient volume.
  6. Monitor, analyze and resolve "pre-error" rejections that occur when data is transferred from Nextgen to EZCAP.
  7. Run sweeps to resolve "pre-error" rejections and create weekly and monthly summary reports along with trending data.
  8. Prepare and maintain documentation for all EDI applications and operational procedures.
  9. Participate in weekly and/or monthly technical conferences and IT meetings and monitor progress, and coordinate with AVP of Managed Care Operations and Claims Operations Director to plan effective solutions.
  10. Read and analyze large and complex data files.
  11. Identify trends and discrepancies in large volume results.
  12. Provides highly complex analytical support through the analysis and interpretation of data in support of root cause analysis, preventative and/or corrective actions and data reconciliation.
  13. Develop, prepare and analyze highly complex reports for management.
  14. Proactively communicate and collaborate with clearinghouses and contracted health plan to reconcile encounter data submissions.
  15. Work with PACE department to monitor, analyze and resolve encounter data related issues.


  1. Bachelor’s degree in a healthcare related or information technology field of study or a combination of related experience.
  2. Four (4) years of experience in analysis and submissions of claims data and 2 years’ experience in a healthcare setting.
  3. Experience with EDI solutions and/or EDI related programs.
  4. Experience with clearinghouse software (TransUnion, Office Ally, etc.) for resolving encounter data claims.


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