Job Description

The  EDI Specialist  role will analyze, troubleshoot, and support data interchanges and supporting processes. This role will ensure these processes are working properly to enable efficient exchange of information between the PM system and clearinghouse utilized by Skin and Cancer Institute. This professional will be responsible for assessing the business needs, analyzing data interchange files, maintaining, and troubleshooting EDI issues identifying root cause analysis and optimization opportunities.

ESSENTIAL DUTIES

• Maintenance, troubleshooting, and support of existing data interchanges, including Ingestion, extraction, and reconciliation of data files from all sources.
• Support and remediation of files and data sent to regulatory partners, including CMS. Serve as the primary resource for researching and correcting encounter data rejections.
• Provides education to internal resources and external trading partners concerning EDI guidelines and capabilities.
• Analyze data, business rules, and companion guides to create accurate and effective EDI mapping documents for existing and new data interchanges.
• Analyze requirements, test systems, export data in EDI formats, and be able to load and transform EDI files into accessible data formats.
• Document all analysis and reporting projects following established department protocols to ensure transparency and repeatability.
• Create and operate within time-based workflows, ensuring data interchange occurs on time and within accuracy constraints of trading partners and regulators.
• Maintain knowledge of existing and emerging regulatory changes and how they impact operational processes and beyond.
• Operate and maintain SFTP connections with existing and new trading partners, including working with IT resources to implement SFTP connections.
• Collaborate with other departments and trading partners to research, identify and correct systemic data errors and ensure data is of the highest quality.
• Participates in the development of coding and billing strategies, evaluating processes related to Revenue Cycle and making recommendations while ensuring compliance with any relevant rules or regulations (including HIPAA, Medicaid, Medicare, and specific 3 rd Party Payors).
• Collaborates with revenue cycle leadership to ensure compliance with all claims transmission.
• Maintains professional relationships and collaborates across teams, managing projects, facilitating meetings and presenting in various settings, including senior leadership.
• Prepares and coordinates revenue cycle responsibilities within the acquisition/implementation process. This includes but is not limited to staff onboarding, vendor management, and clearinghouse management.

SKILLS/QUALIFICATIONS/EXPERIENCE

• Minimum of 2-3 years of EDI experience in a health plan or managed care is required.
• 2+ years of experience in a remote working environment.
• Must have a high school diploma or equivalent certificate.
• Demonstrated experience and understanding of data sets and formats such as ANSI files: X12, HL7, and FHIR standards.
• Hands on experience having implemented 834 & 837 files for a health plan, build and troubleshoot carrier forms, and ensure accurate and efficient data exchange.
• Proven ability to impact process improvement and efficient operations.
• High level of business and technical knowledge with significant practical experience in healthcare administration or operations preferred
• Communicate effectively with internal staff and insurance companies.
• Collaborative and humble approach with internal and external resources.
• Able to prioritize and organize daily tasks.
• Strong attention to detail, positive attitude and a proven ability to lead a team to success.
• Proficient in Microsoft Word, Outlook and Excel.
• Knowledge of state regulations.

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