Job Description
We are seeking a Senior Encounter & Risk Adjustment Technical Lead to support healthcare payer operations focused on ACA Exchange Risk Adjustment, CMS EDGE submissions, encounter data quality, and healthcare data integration.
This is a hands-on technical leadership role responsible for troubleshooting complex healthcare data issues, improving encounter data quality, supporting CMS EDGE processes, and partnering across business, IT, data, and vendor teams. This is not a project management role.
• Lead technical troubleshooting of encounter and risk adjustment data issues
• Analyze CMS EDGE submission errors and drive resolution
• Support encounter reconciliation, validation, and error remediation activities
• Partner with business, operations, data, IT, and vendor teams
• Improve encounter acceptance rates and overall data quality
• Translate CMS and business requirements into technical solutions
• Provide technical guidance to developers and analysts
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.
Required Skills & Experience
• Direct experience supporting ACA Exchange Risk Adjustment
• Hands-on experience with CMS EDGE Server submissions, reconciliation, validation, and error remediation
• Strong understanding of healthcare payer data, including:
o Claims
o Encounters
o Enrollment
o Diagnosis data
• Advanced SQL skills for data analysis, validation, and troubleshooting
• Experience with healthcare EDI transactions:
o 837 Professional/Institutional Claims
o 834 Enrollment
• Experience with healthcare integration platforms such as:
o Edifecs
o IBM ITX (Transformation Extender)
o Similar healthcare EDI/integration tools
• Experience working in HIPAA-regulated healthcare environments
• Proven ability to troubleshoot complex healthcare data pipelines and submission issues
Nice to Have Skills & Experience
• HHS-HCC Risk Adjustment experience
• Encounter acceptance/rejection analysis
• CMS audit support
• Data quality improvement initiatives
• Healthcare data warehouse or data lake environments
• Databricks or cloud-based healthcare data platforms
• Technical leadership or mentoring experience
• Vendor management experience
Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.