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Director of Health Care Informatics and Encounters in Jacksonville, Florida at One Call

Date: 4/4/2019

Job Snapshot

Job Description

Director of Health Care Informatics and Encounters

The Director of Health Care Informatics and Encounters will support client retention and growth by ensuring client and the respective government program (Medicaid and Medicare) requirements are defined, implemented, and adhered to. This role requires strong business acumen, implementation skills and an extensive informatics and claims background.  This role will be responsible for reaching its goal by liaising with the Customer and internal One Call staff to ensure data integrity and contractual obligations are met.

  • Responsible for the successful implementation of products and services as they relate to the Group Health government programs (Medicaid/Medicare) segment, while establishing efficient, effective and repeatable processes to ensure all projects and requests receive the appropriate level of attention and prioritization.

  • Gather and understand customer business objectives and requirements and lead the implementation of solutions, services or changes with a cross functional team across One Call Business Units and Shared Services as well as the customer organization.

  • Act as Medicaid and Medicare expert on HIPAA EDI transaction sets based on ASC X12 5010 Companions guidelines, including but not limited to the following files and data exchanges; 276, 277, 820, 834, 835, 837I, 837P, 837D, 999, NCPDP, and Capitation Reporting. 

  • Act as Medicaid and Medicare expert on RFP Responses, Recipient Eligibility Verification methods, including but not limited to the following files and data exchanges; 270, 271, MEVS, and AVRS. 

  • Comprehensive understanding of Medicaid and Medicare claim billing guidelines and validation edits to ensure successful encounter submission and acceptance; including but not limited to the following files and data exchanges; Crossovers, Coordination of Benefits, Explanation of Benefits, Remittance Files, Third Party Liability, Wraparound payment, Expanded Benefits and 256 CARC/RARC. 

  • Comprehensive understanding of Safe Harbor connection rules according to CAQH-CORE standards.

  • Comprehensive understanding of how capitated and fee-for-service financial arrangements impact data submission and encounter acceptance.

  • Comprehensive understanding of Provider Enrollment requirements and impacts on Encounter acceptance.

  • Construct and oversee a program that allows One Call to exceed successful Encounter submission thresholds within appropriate timeframes. Remediate all rejections or denials within contractual/program timeframes.

  • Benchmark, analyze, report on and make recommendations for improvements and growth of IT systems and internal processes to reduce rework and improve efficiencies

  • Collaborate with Legal and Sales as it relates to customer contracts, ensuring that requirements can be operationalized and are in the best interest of the parties.

  • Provides training to the operations staff during implementation and continuously after “go live”

  • Conduct post-delivery lessons learned and create appropriate action plans to reduce inconsistencies and identify areas of improvement

  • Ensure that all appropriate documentation for new account activity is being maintained and updated properly.

  • Identify and align the appropriate levels of resources to execute tasks.

  • Bachelor’s degree with equivalent relevant industry or work experience.

  • 8 years prior government program experience with customer onboarding/implementation, project management, client management, knowledge of business processes, and handling of multiple projects that are deadline oriented.

  • 2 years of prior experience interacting with regulators for State Medicaid plans. Including Readiness Reviews and Audits

  • If working with federal government contract clients, an employee is required to receive federal government clearance for handling sensitive information. Employee is also required to receive annual security awareness training.

  • Exceptional influence management

  • Strong Project management skills

  • Expansive knowledge of HIPAA X12 834 Eligibility Files, as well as other HIPAA X12 inbound/outbound files (270/271, 820, 835, 837)

  • Strong communication skills – written, oral, facilitation, negotiation, conflict resolution

  • Customer facing experience with One Call customers preferred

  • Operational understanding of One Calls value proposition and business workflows

  • Exceptional organizational skills

  • Managed Care and/or Workers Comp industry experience

  • Ability to work independently in an environment with fluid priorities and multiple stakeholders

  • Ability to interface with IT and understand/communicate technical requirements

  • Ability to ask incisive questions and challenge assumptions to uncover potential barriers to success

  • Intermediate use of Word, Excel, PowerPoint, MS Project, SharePoint &

  • Travel - may be required

  • Location – Remote with Regular travel to Jacksonville as needed


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