Manager Medicare Encounters

Job ID: J114720
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:




This job provides application software development management for IT projects. Creates plans and manages activities, within an assigned unit/area. Assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Foresees organizational impacts and understands the procedures associated with introducing new technologies.   Leads team in the areas of scheduling, direction, future planning and standard practices.    Monitors and controls quality while actively seeking opportunities for improvement. Establishes and meets scheduled milestones for deliverables. 


  • Communicate effectively with all levels of the Organization.
  • Managing customer and expectations; facilitating, planning and meetings; translating customer expectations for staff and peers; representing the Organization with outside entities.
  • Prepare written procedures, policies, reports and correspondence; collaborate and negotiate with departments corporate wide.
  • Collaborate with company customers, staff, IT colleagues, and other stakeholders in identifying customer requirements, assessing impacts to other areas, considering available options, comparing costs and benefits, and recommending solutions.
  • Identify issues and recommend solutions.
  • Create presentation and present concept to clients, tailoring presentation to audiences of varies levels, subject knowledge and size.
  • Implement recommendations/solutions and ensure client receives the necessary assistance to carry out solutions.
  • Liaising with clients to keep them informed of progress and to make relevant decisions.
  • Advise clients on options, risks, cost vs benefit, impact on other business processes and system priorities.
  • Ensure continuous improvement of processes and delivery of results within assigned unit/area. 
  • Organize, direct and coordinate cross-functional activities including staff not under direct managerial control.
  • Encourage innovation and focus resources to ensure successful delivery of desired results.
  • Apply quantitative risk assessment to team's assignments to understand potential threats and the probability they will occur.
  • Lead team in mitigating risks and applying appropriate contingency plans to ensure minimal impacts to customers.
  • Provide leadership to the Organization to respond to business opportunities/challenges, new technologies, legislation and other environmental factors. 
  • Oversee analysis of issues or needs and review recommended solutions.
  • Assess the impact of strategic business and technical changes on the environment.
  • Responsible for managing all activities within an assigned business unit/area.
  • Foresee organizational impacts and understand the procedures associated with introducing new technologies, while seeking ways to collaborate with other teams outside area of responsibility to facilitate transitions.
  • Optimize the utilization of resources by applying appropriate concepts, technologies and workflows.
  • Accept direction and provide leadership to develop/maintain a high-performance work team.
  • Respond to feedback and champion process improvement initiatives by empowering their team to deliver quality services/products to internal and external customers. 
  • Implement solutions that are consistent with Highmark’s strategic direction.
  • Keep abreast of current industry standards and trends.
  • Develop and provide input to skills assessment and oversee personal development plans as it relates to career development.
  • Coach, manage and develop employees by establishing clear goals, expectations, and strategies for employee performance.
  • Develop and administer performance reviews with measurable goals.
  • Provide opportunities for staff to maintain current industry knowledge.
  • Provide opportunities for employees to build collaborative relationships with customers.
  • Conduct Departmental Management planning and administrative functions. 
  • Responsible for Departmental budgeting and fiscal responsibilities.
  • Manage teams that span geographic areas or functional areas.
  • Ensure compliance with corporate standards, policies and regulations (SOX, SSP, DIACAP, PHPLC, etc.).
  • Establish and use metrics as a tool to benchmark and improve operational excellence
  • Develop and implement short-term and long-term departmental plans.
  • Consult and evaluate vendor solutions where appropriate.
  • Other duties as assigned or requested.



  • Bachelor’s Degree
  • 5 years of experience in a leadership / mentoring role.
  • 5 years’ experience in planning, implementing, maintaining and growing capabilities within relevant discipline
  • 3 years’ experience in developing, communicating and presenting concepts to varying audience.


  • Master’s Degree
  • Prior experience managing a team of Analysts who are responsible for the timely correction/troubleshooting, submission, and analysis  of Medicare encounters
  • Knowledge and experience of CMS submission requirements for Medicare Encounters (RAPS and EDPS)
  • Knowledge of Electronic Data Interchange (EDI) transaction sets – ie. 837, PDE, NCPDP, etc.
  • Experience in establishing and monitoring controls in a healthcare operations environment (including Claims, Provider, etc) to support efficient encounters submission and acceptance
  • Highly prefer experience in managed care encounters or provider accounts receivables management (medical billing and payment practices)
  • Support reporting deliverables and reconciliation efforts for revenue optimization
  • Manage testing efforts as requested by CMS and introduce tools and methodologies to streamline internal processes
  • Identify process improvement opportunities and enhancements based upon errors and exceptions
  • Provide strategic guidance to ensure accurate reporting for revenue and risk score optimization
  • Support prompt Root Cause Analysis and the establishment of short and long term solutions
  • Promote collaboration and work with team to achieve corporate and departmental strategic priorities and objectives.
  • Work directly with external entities (ie. CMS) to ensure oversight and manage performance expectations in accordance with Service Level Agreement (SLA) and contractual obligations
  • Management experience in employee development plans, performance evaluations and goals development
  • Experience in budget administration and process improvement.
  • Knowledge and experience in developing strategic plans.
  • Demonstrated competency in the execution of multiple projects, including managing resources across multiple projects to meet goals.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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