Facets EDM Analyst

We are seeking a highly experienced Encounter Data Manager (EDM) with deep Facets configuration and claims expertise to support healthcare payer clients. This role focuses on end-to-end encounter data lifecycle management, including 837 transaction processing, claims alignment, and regulatory compliance (CMS/Medicaid/Medicare). Key Responsibilities • Lead end-to-end encounter submission processes, ensuring compliance with CMS and state Medicaid guidelines • Monitor, analyze, and resolve encounter submission errors using automated workflows and root cause analysis • Ensure accuracy, completeness, and timeliness of encounter data submissions to maximize acceptance rates and minimize rejections • Configure and validate Facets components across claims, benefits, pricing, and rules to ensure proper adjudication outcomes • Align encounter data processes with claims adjudication logic, 837/835 transaction flows, and EDI processing • Troubleshoot configuration and data issues impacting claims processing, encounters, and regulatory submissions • Validate and reconcile data across multiple systems to ensure accurate encounter submissions and minimize financial risk • Identify data gaps, mismatches, or revenue leakage risks related to Medicare Advantage and Medicaid • Implement improvements to increase encounter acceptance rates and reduce resubmissions • Partner with Claims, EDI, IT, Enrollment, and Compliance teams to support encounter processing and issue resolution • Translate business requirements into functional specifications and configuration designs • Provide guidance to client stakeholders on best practices for encounter management and compliance • Drive workflow automation and operational efficiencies in encounter submission and reconciliation processes • Support testing cycles (UAT, regression, validation) for new configurations or system enhancements • Document configuration decisions, workflows, and system dependencies Required Qualifications • 5+ years of healthcare payer experience (Medicare andMedicaid) • 5+ years of hands-on experience with Facets (TriZetto) and EDM across claims and configuration modules • Strong experience with: • 837/835 transactions and EDI processing • Encounter data submissions and reconciliation • Claims adjudication processes • Proven ability to: • Analyze and resolve complex data and configuration issues • Interpret CMS and regulatory requirements • Experience working in consulting or client-facing environments Preferred Qualifications • Experience with TriZetto Encounter Data Management (EDM) solutions • Background in risk adjustment, revenue cycle, or payment integrity • Strong SQL/data analysis capabilities • Experience supporting large-scale payer implementations, migrations, or transformations