Job Description

Huron helps its clients drive growth, enhance performance and sustain leadership in the markets they serve. We help healthcare organizations build innovation capabilities and accelerate key growth initiatives, enabling organizations to own the future, instead of being disrupted by it. Together, we empower clients to create sustainable growth, optimize internal processes and deliver better consumer outcomes.

Health systems, hospitals and medical clinics are under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Investing in new partnerships, clinical services and technology is not enough to create meaningful and substantive change. To succeed long-term, healthcare organizations must empower leaders, clinicians, employees, affiliates and communities to build cultures that foster innovation to achieve the best outcomes for patients.

Joining the Huron team means you’ll help our clients evolve and adapt to the rapidly changing healthcare environment and optimize existing business operations, improve clinical outcomes, create a more consumer-centric healthcare experience, and drive physician, patient and employee engagement across the enterprise.

Join our team as the expert you are now and create your future.

Huron is a global consultancy that helps healthcare organizations drive performance transformation and deliver sustainable growth. We partner with payer organizations to optimize core operations, enhance regulatory compliance, and improve financial outcomes.

We are seeking a highly experienced Encounter Data Manager (EDM) with deep Facets configuration and claims expertise to support healthcare payer clients. This role focuses on end-to-end encounter data lifecycle management, including 837 transaction processing, claims alignment, and regulatory compliance (CMS/Medicaid/Medicare).

Key Responsibilities

• Lead end-to-end encounter submission processes, ensuring compliance with CMS and state Medicaid guidelines
• Monitor, analyze, and resolve encounter submission errors using automated workflows and root cause analysis
• Ensure accuracy, completeness, and timeliness of encounter data submissions to maximize acceptance rates and minimize rejections

• Configure and validate Facets components across claims, benefits, pricing, and rules to ensure proper adjudication outcomes
• Align encounter data processes with claims adjudication logic, 837/835 transaction flows, and EDI processing
• Troubleshoot configuration and data issues impacting claims processing, encounters, and regulatory submissions

• Validate and reconcile data across multiple systems to ensure accurate encounter submissions and minimize financial risk
• Identify data gaps, mismatches, or revenue leakage risks related to Medicare Advantage and Medicaid
• Implement improvements to increase encounter acceptance rates and reduce resubmissions

• Partner with Claims, EDI, IT, Enrollment, and Compliance teams to support encounter processing and issue resolution
• Translate business requirements into functional specifications and configuration designs
• Provide guidance to client stakeholders on best practices for encounter management and compliance

• Drive workflow automation and operational efficiencies in encounter submission and reconciliation processes
• Support testing cycles (UAT, regression, validation) for new configurations or system enhancements
• Document configuration decisions, workflows, and system dependencies

R equired Qualifications

• 5+ years of healthcare payer experience (Medicare and Medicaid)
• 5+ years of hands-on experience with Facets (TriZetto) and EDM across claims and configuration modules
• EDM - Business Components
  • Translation
  • Business Rules and Scrubbing
  • Submission and Response
  • Online Editing

Reconciliation & Auditing

• Strong experience with:
  • 837/835 transactions and EDI processing
  • Encounter data submissions and reconciliation
  • Working knowledge of claims payment systems
  • Claims adjudication processes
• Proven ability to:
  • Analyze and resolve complex data and configuration issues
  • Interpret CMS and regulatory requirements
    • Government Programs Compliance Requirements
    • Medicare CMS Requirements, Timelines, and Penalties
    • Medicaid State Requirements, Timelines, and Penalties
    • Business and Data Scalability
    • Revenue Management
    • New Opportunities / Markets
    • New Government Requirements (Duals, APCD, HIX, ETC)
• Experience working in consulting or client-facing environments
• Ability to communicate with technical and non-technical staff is a must, will interact with developers about requirements, partners about enhancements with clients regarding implementation and application usage
• Effective and efficient communication

Preferred Qualifications

• Experience with TriZetto Encounter Data Management (EDM) solutions
• Background in risk adjustment, revenue cycle, or payment integrity

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Position Level

Consultant

Country

United States of America