The Senior Encounter Data & Coding Specialist is responsible for ensuring the completeness, accuracy, and regulatory compliance of encounter data, diagnosis coding, and supporting clinical documentation for CMS, Medicare, Medicaid, and PACE reporting.
This senior individual-contributor role combines encounter oversight, coding validation, error resolution, reconciliation, concurrent and retrospective coding review, and clinical documentation improvement. The specialist works closely with clinical staff, providers, Health Information Management (HIM), and Information Technology teams to identify and resolve encounter and coding discrepancies while supporting revenue integrity, risk adjustment, and regulatory compliance.
Key responsibilities include:
- Reviewing, validating, monitoring, and reconciling encounter data submissions
- Investigating encounter rejections, edits, denials, and discrepancies
- Correcting and resubmitting encounter records as needed
- Performing reconciliation across EHRs, billing systems, claims systems, and CMS submission reports
- Monitoring acceptance, rejection, and resubmission trends and escalating issues with corrective actions
- Maintaining encounter data quality controls
- Conducting concurrent and retrospective coding reviews
- Assigning and validating ICD-10-CM diagnosis codes based on clinical documentation
- Supporting accurate capture of chronic conditions and risk-adjusting diagnoses
- Identifying documentation gaps and initiating provider queries
- Analyzing CMS submission reports and preparing reports for leadership and operational teams
- Supporting Medicare risk adjustment, audits, policy development, and staff education
Qualifications
- Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, Business Administration, or a related field preferred
- Minimum 5 years of healthcare experience in encounter data, medical coding, revenue cycle, risk adjustment, or Health Information Management
- Minimum 3 years of experience with PACE, Medicare Advantage, managed care, risk adjustment, or encounter data; direct PACE experience preferred
- Experience investigating encounter submission errors and performing reconciliation activities
- CPC, CRC, CCS, RHIT, or RHIA preferred; CPC or CRC strongly preferred
- Demonstrated knowledge of ICD-10-CM coding guidelines
- Knowledge of Medicare risk adjustment methodologies, CMS Encounter Data System requirements, EHRs, revenue-cycle workflows, claims and encounter processing, and CMS regulatory requirements
- Advanced Microsoft Excel skills preferred; SQL, Power BI, and healthcare analytics tools are a plus
- Strong analytical, organizational, problem-solving, written, and verbal communication skills
Location
Oakland, California, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$95,721 - $145,496
Remote work allowed
No
Posted
3 weeks ago