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Aledade is the largest network of independent primary care.
The Role
Lead design and implementation of encounter data submission and reconciliation program, create SOPs, manage ASM payer submissions, reconcile CMS/payer files, monitor diagnosis submission quality, and evaluate ASM ROI.
Summary Generated by Built In
The Encounter Data Submissions Program Manager will assist in the development of an end to end Encounter Data Submission and Reconciliation program, to include creation of program guide and standard operating procedures. The program manager will collaborate across teams to better understand and evaluate ROI of existing Alternate Submission Method (ASM) workstreams, as well as potential ROI improvements as a result of workflow efficiencies and enhancements. Additionally, once established, the program manager will oversee daily EDS and reconciliation processes.
This Manager will lead the design and implementation of Aledade’s end-to-end Encounter Data Submission and Reconciliation program, including the creation of comprehensive program guides and Standard Operating Procedures. You will act as a cross-functional leader, evaluating the ROI of existing Alternate Submission Method (ASM) workstreams and driving workflow enhancements that directly improve data accuracy and operational efficiency.
Once established, you will provide oversight of the daily EDS and reconciliation processes, ensuring that clinical encounter data—the lifeblood of value-based care—is accurately captured, validated, and submitted to payers and CMS with total integrity.
We are flexible with respect to geographic location, and the ideal candidate will be comfortable working remotely/work from home within the US or be based from Bethesda, MD office.
Primary Duties
- Assist in the development of programming documentation and SOPs, to include routine maintenance and update of program documents
- Identify and establish ASM process with additional eligible payers
- Provide support to CSO in efforts to increase practice “opt-in” to ASM processes
- Create and transmit ASM files to all relevant payers on an established cadence
- Maintain annual CMS and payer submission deadlines
- Maintain and update payer specific ASM templates annually
- Maintain and update payer specific submission methods annually
- Reconcile ASM record submissions with payer and CMS EDS files
- Establish routine reconciliation process with payer and CMS files
- Integrate accepted ASM submitted diagnosis data into existing risk reporting dashboards
- Provide ongoing monitoring of provider diagnosis submission and truncation trends
- Develop process for consistent monitoring of existing dropped diagnosis and truncation dashboards for early identification of diagnosis submission errors
- Collaborate with senior leadership and legal partners to ensure continued compliance with regulatory requirements pertaining to submission of “add” and “delete” diagnoses
- Develop a process to identify and submit diagnoses appropriately identified through routine CDI chart audits.
- Conduct annual ROI evaluation of ASM processes to include both submission of “dropped” diagnoses, and retrospective chart audit projects
Minimum Qualifications
- Bachelor's degree in Business, Finance, Information Technology, Analytics, Operations, or a related field
- 4+ years of experience with Medicare Advantage or ACA encounter data processes and/or risk adjustment experience with a Payer, Vendor or Provider Organization
- 1+ years of X-12 837 data knowledge
- Strong analytical skills with a proven ability to interpret complex data sets and identify key insights
- Ability to develop and present information to Senior Leadership
- Working knowledge of SQL: writing, creating and/or running queries
- Software Proficiency: Proficiency in using common business software such as Microsoft Office Suite (Word, Excel, PowerPoint), collaboration tools (e.g., SharePoint), and project management software (e.g., Jira, Smartsheet)
Preferred knowledge, skills, and/or abilities
- Excellent communication and presentation skills, both written and verbal
- Business Process Reengineering (BPR): Familiarity with BPR principles and methodologies to radically redesign business processes for improved performance, efficiency, and customer satisfaction
- Medicare claims experience
- Fundamental understanding of relational databases
Physical Requirements
- Prolonged periods of sitting at a desk and working on a computer.
Who We Are:
Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of health plans, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?
At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:
Flexible work schedules and the ability to work remotely are available for many roles
Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners
Robust time-off plan (21 days of PTO in your first year)
Two paid volunteer days and 11 paid holidays
12 weeks paid parental leave for all new parents
Six weeks paid sabbatical after six years of service
Educational Assistant Program and Clinical Employee Reimbursement Program
401(k) with up to 4% match
Stock options
And much more!
At Aledade, we don’t just accept differences, we celebrate them! We strive to attract, develop and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.
Privacy Policy: By applying for this job, you agree to Aledade's Applicant Privacy Policy available at https://www.aledade.com/privacy-policy-applicants
Top Skills
JIRA
Excel
Microsoft Powerpoint
Microsoft Word
Relational Databases
Sharepoint
Smartsheet
SQL
X12 837
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The Company
What We Do
Aledade is the largest network of independent primary care, enabling clinicians to deliver better patient outcomes and generate more savings revenue through value-based care. Aledade’s data, personal coaching, user-friendly workflows, health care policy expertise, strong payer relationships and integrated care solutions enable primary care organizations to succeed financially by keeping people healthy. Together with more than 1,900 practices and community health centers in 45 states and the District of Columbia, Aledade manages accountable care organizations that share in the risk and reward across more than 200 value-based contracts representing more than 2.5 million patient lives. To learn more, visit www.aledade.com or follow on X (Twitter), Facebook or LinkedIn.
Why Work With Us
At Aledade, we’re all about doing good for patients, practices and society - which is why we’re so passionate about value-based care and the work we do every day. Because we’re working to benefit all of society, we believe the best way to do so is to utilize all of our team members and their unique experiences, interests, backgrounds and beliefs.
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