Leads the end-to-end encounter data submission and reconciliation strategy for payers and CMS. Oversees ASM file transmission, diagnosis tracking, acceptance metrics, root-cause analysis, compliance, process documentation, and corrective actions. Partners with internal teams, vendors, payers, legal, finance, and analytics to improve data quality, reporting, operational efficiency, and financial results. Requires expertise in Medicare Advantage or ACA encounter data, risk adjustment, X12 837 transactions, CMS EDPS reporting, SQL, and complex program management.
The Manager, Clinical Data Management is responsible for the full lifecycle of our Encounter Data Submission and Reconciliation strategy, ensuring that diagnoses are accurately tracked, submitted, and accepted by payers and CMS. In this role, you’ll lead the operational and strategic work that turns clinical documentation into reliable, compliant, and financially meaningful data. You’ll collaborate across internal teams, vendors, and payers to spot gaps early, solve root causes, and continuously improve how we submit and reconcile encounter data. If you thrive at the intersection of healthcare data, process ownership, and cross-functional leadership, this role offers the chance to make a measurable difference.
Primary Duties
- Oversee end-to-end strategy, priorities, and operations for accurate and compliant encounter data submission to payers and CMS.
- Create and transmit ASM files on established cadences, maintaining payer-specific templates and submission methods annually.
- Establish routine reconciliation processes to track diagnoses from documentation to acceptance, quantifying gaps and identifying dropped/truncated records early.
- Lead root-cause analysis and corrective action across internal teams, vendors, and payers for rejected or dropped diagnoses.
- Partner with operations leadership to drive strategy, chart selection, and annual evaluation for the retrospective chart review initiative.
- Monitor submission metrics and acceptance rates, applying data scrubs and business rules to meet regulatory standards and CMS/payer deadlines.
- Collaborate with leadership and legal partners to ensure full compliance regarding add and delete diagnosis workflows.
- Develop and maintain process documentation, SOPs, and routine workflow updates.
- Identify tools and long-term strategies to improve encounter acceptance rates, minimize manual effort, and expand ASM processes across eligible payers.
- Evaluate annual ROI across submission and audit processes, optimizing workflows to drive financial performance.
- Lead cross-functional initiatives with key stakeholders to resolve data flow issues and implement system updates.
- Integrate accepted ASM submitted diagnosis data into existing risk reporting dashboards and build new recurring reports for leadership
- Own ASM valuation and financial results, partnering with Data and Analytics on metric definitions and data quality Other duties as assigned
Data Submission & Reconciliation Process
Compliance & Quality Assurance
Process Improvement
Cross-Functional Collaboration
Minimum Qualifications
- Bachelor’s degree in Business, Finance, IT, Healthcare Analytics, or Operations
- 6+ years of experience with Medicare Advantage or ACA encounter data processes, and/or risk adjustment experience within a payer, vendor, or Value Based Care organization
- 3+ years of program or project management experience, including ownership of complex, multi-stakeholder initiatives
- 2+ years of working knowledge with X12 837 transaction sets; Working knowledge of CMS EDPS experience (MAO-002/MAO-004 reports)
- Strong analytical capabilities with a demonstrated ability to interpret complex datasets and synthesize actionable insights
- Excellent written and verbal communication skills, with proven experience developing and presenting key information to executive leadership
- Working knowledge of SQL, including writing, modifying, and executing queries
- Proficiency in Google Workspace, project tracking software (i.e. Jira, Smartsheet), and business intelligence or dashboard platforms
Preferred Qualifications
- Familiarity with Business Process Reengineering (BPR) principles and methodologies to optimize processes for enhanced efficiency and performance
- Experience with chart selection or targeting strategies for retrospective chart review
- Fundamental understanding of relational databases
Physical Requirements
- Prolonged periods of sitting at a desk and working on a computer
Who We Are:
Aledade PBC, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of health plans, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?
At Aledade PBC, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:
Flexible work schedules and the ability to work remotely are available for many roles
Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners
Robust time-off plan (21 days of PTO in your first year)
Two paid volunteer days and 11 paid holidays
12 weeks paid parental leave for all new parents
Six weeks paid sabbatical after six years of service
Educational Assistant Program and Clinical Employee Reimbursement Program
401(k) with up to 4% match
Stock options
And much more!
At Aledade PBC, we don’t just accept differences, we celebrate them! We strive to attract, develop and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.
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