EDI Data Analyst

ESSENTIAL JOB FUNCTIONS:
Work with IT to ensure scheduled health plan encounter data submissions are timely, accurately, and meet industry and individual health plan requirements.

Contact for health plans regarding encounter data submissions, serving as a resource and liaison.

Responsible for managing special reconciliation tasks with health plans while collaborating with IT.

Analyzes, interprets and documents encounter data to identify potential issues and trends.

Coordinate and perform the correction of data rejections so that files may be resubmitted, error free.

Directly respond to external and internal customers’ encounter data issues which may arise, ensuring resolution to customer satisfaction.

Conduct monthly reconciliation audit of encounter data submissions by IT.

Maintain clear documentation of encounter data workflow by health plan and submission method, including process by individual line of business.

Responsible for identification, recommendation, coordinating request and implementation of enhancement(s) to ensuring compliance.

Supports department projects/tasks as they arise. This includes generating standard and ad-hoc reports, managing contact list, and monitoring metrics.

Serves as backup to regularly scheduled Encounter Data Workgroup meetings.

Contribute to team effort by accomplishing related results as needed.

QUALIFICATIONS & REQUIREMENTS:
Job related Knowledge, Skills, and Abilities, including Documentation, if pertinent.

Bachelor’s Degree in Business, Information Systems (or related field), or equivalent experience, required.

Minimum of three years experience in operations, data analysis, or information management – in healthcare industry is strongly preferred.

Creative, Problem-solving, and Innovation Skills.

Strong oral and written communication skills. Ability to clarify policies. Relies on extensive experience and judgment to plan and accomplish goals. Ability to work independently, organize and prioritize work. Must be able to demonstrate the ability to make decisions and resolve issues.

Customer Focused and Communication Skills.

Ability to communicate and work well with internal and external customers. Independent decision making skills and demonstrated ability to take initiative to resolve issues.

EDUCATION AND/OR TRAINING :
Minimum of 3+ years of experience in operations, data analysis or information management in the insurance and/or delivery system in the healthcare industry is strongly preferred

Minimum of two years analytical experience in a support role is preferred

BA/BS degree in Business, Information Systems or other related field preferred or equivalent experience and training

SKILLS AND ABILITIES:
Strong understanding of the healthcare environment and IT infrastructure is preferred

Have EDI, HIPAA and Healthcare expertise with business and technical expertise

In-depth knowledge of X 12 EDI formats and structures, EDI technology options and EDI data exchange implementation, CAQH regulations and core requirements and trading partner management oversight

Must have knowledge of healthcare administrative functions, including claims processing, remittance advice processing, eligibility, verifications, etc.

Understanding of CMS Risk Adjustment & HCC Methodology preferred

Current and progressive healthcare experience in both provider and payer domains

Must have Government billing regulations experience, including; Medicare, Medicare Managed Care, and Medical Terminology

Excellent analytical, problem-solving and writing skills

Strong database and MS skills, including queries and, spreadsheet