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   Current UPMC employees must apply in HR Direct

Manager, Medicare Encounters (Remote)

Description

UPMC Health Plan's Medicare HCC team is seeking a Manager, Medicare Encounters!

The Risk Adjustment Department is a large department with many responsibilities and diverse skillsets. This position will manage the Medicare Encounter Data Submission, which is not only a critical area of the department but also a driver of Medicare Revenue for UPMC Health Plan.   


This position is responsible for the creation and submission of Medicare Encounter (EDPS) and Risk Adjustment Processing System (RAPS) Data to CMS as well as applicable state entities. Reconciliation, tracking, and reporting of all CMS Response Files to ensure complete, accurate, and timely submission. Maintaining internal software, servers, and databases to support operations and reporting. Managing internal and contracted staff. Manage software and system upgrades. Reporting and managing EDPS and RAPS Data Submission for any TPA business as applicable. Responsible for the oversight of activities that ensure regulatory compliance related to risk adjustment operations.

Strong preferences:

  • High-level SQL Server
  • Microsoft Excel
  •  Medical claims knowledge

This is a work from home position!


Responsibilities:

 

  • Develop and maintain internal Standard Operating Procedures (SOPs) and documentation as necessary Manage and own other special projects as assigned
  • Participate in various Government, Vendor or other entity hosted webinars, training, and conferences Monitor Federal and State Guidance to ensure compliance with Risk Adjustment requirements
  • Managing contracted staff Reporting and identifying trends related to Medicare data submission Creation of productivity reports, key performance indicators, dashboards, and other reporting as needed
  • Managing software upgrades Maintaining internal databases for reporting and analysis across the organization Managing internal staff
  • Creation and Submission of Medicare Encounter Data (EDPS) for UPMCHP, PACE, and TPA business to both CMS and State Entities Creation and Submission of Risk Adjustment Processing System (RAPS) for UPMCHP, PACE, and TPA businessMaintaining and reconciling vendor software for EDPS and RAPS

 

Qualifications

  • Master's level degree in business, finance, economics, mathematics, healthcare administration, statistics, information systems, or closely related discipline
    • With a minimum eight (8) years of relevant experience (e.g., healthcare, finance or information systems) required;
  • or a Bachelor's degree with ten (10) years of experience required
  • Advanced Structured Query Language (SQL) required
  • Excellent organizational and leadership capabilities with previous staff supervision required Excellent Microsoft Office skills required Ability to multi-task required
  • Self-motivated individual with an ability to work independently required
  • Working knowledge of databases required
  • Ability to work in a fast-paced environment required Ability to establish and meet deadlines required
  • Knowledge of Medicare data files (837, 277, MAO-002, MAO-004, MOR, MMR) preferred
  • Knowledge of ICD Diagnosis, CPT, UB, HCFA coding and understanding preferred
  • Previous healthcare claims experience preferred


Licensure, Certifications, and Clearances:

  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct