Claims & Encounter EDI Analyst

Under the direction of the Sr. Director of Healthcare Analytics, this position is responsible for the accurate and timely processing, tracking, analysis, and transmission of electronic claim and encounter data.  The Claims & Encounter EDI Analyst performs all functions of the Claims & Encounter EDI Coordinator, including established daily, weekly, and monthly claim and encounter processing responsibilities. In addition, this position performs advanced technical and analytical functions related to EDI file processing, encounter submission, rejection analysis, file mapping, testing, and issue resolution.  The Analyst is responsible for investigating claim and encounter processing issues, analyzing rejection trends, identifying opportunities to improve encounter acceptance, and maintaining EDI file mappings in response to changing health plan, clearinghouse, regulatory, and business requirements.  The Analyst also assists with the development, configuration, testing, and implementation of EDI processes and mappings for new health plans and trading partners. Success in this position requires strong attention to detail, analytical and problem-solving skills, knowledge of healthcare claim and encounter data, and the ability to independently research and resolve non-routine EDI issues while continuing to reliably perform established production responsibilities.  The Claims & Encounter EDI Analyst serves as a knowledgeable resource and liaison between the organization, clearinghouses, health plans, vendors and internal departments to support accurate, complete, and timely exchange of claim and encounter data.  The Claims & Encounter EDI Analyst will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

• Perform all responsibilities of the Claims & Encounter EDI Coordinator, including daily claim and encounter file in-loads, required processing, reconciliation, tracking, and scheduled encounter file creation and submission.
• Ensure timely and accurate receipt, processing and submission of claim and encounter data according to established schedules and requirements.
• Monitor claim and encounter file processing and independently troubleshoot missing, duplicate, rejected, incomplete, or failed transactions.
• Review and analyze encounter rejections to identify trends, data quality issues, mapping issues or systematic processing problems.
• Research rejection trends and implement or recommend appropriate corrections to improve encounter acceptance and minimize preventable rejections.
• Maintain and modify EDI file mappings in response to health plan, clearinghouse, regulatory, vendor, or internal business requirement changes.
• Configure and/or develop new EDI mappings and related processes for new health plans, trading partners, vendors, or data submission requirements.
• Perform testing and validation of new or modified EDI mappings and processes to ensure file output meets applicable requirements prior to production implementation.
• Review health plan, clearinghouse, and trading partner specifications and translate requirements into appropriate EDI configuration, mapping, testing, and operational changes.
• Reconcile claim and encounter receipt and submission activity to ensure the complete transfer of data between the organization and its trading partners.
• Review clearinghouse acknowledgements, acceptance reports, and rejection reports and perform necessary research, correction, and follow-up.
• Serve as a liaison with clearinghouses, health plan encounter teams, vendors, and internal departments regarding claim and encounter submission requirements, testing, rejections, and issue resolution.
• Assist with the implementation and testing related to new health plans, clearinghouses, vendors, system changes and modifications to existing claim or encounter processes.
• Maintain accurate processing logs, reconciliation records, mapping documentation, technical specifications, procedures, and other required documentation.
• Follow established HIPAA-compliant procedures for the secure transmission and handling of electronic healthcare information.
• Communicate significant processing issues, trends, risks, pending items, and potential missed deadlines to the appropriate team members and supervisor.
• Provide guidance and support to Claims & Encounter EDI Coordinator staff regarding established claim and encounter processing procedures as needed.
• Other duties as assigned.
• This position is eligible for remote/hybrid work consideration. Remote/Hybrid approval will be on a case-by-case basis taking into consideration business needs, performance metrics and an evaluation of the likelihood of the employee succeeding in a remote work arrangement (determined by their supervisor). Employees in a remote work arrangement may be required to attend in person meetings as needed to meet business and departmental needs.

• High School Diploma or equivalent required.
• Minimum of 3 years’ experience in healthcare EDI, claim processing/in-load, encounter submission, healthcare data processing or a related role required. Equivalent combinations of relevant experience and demonstrated competency may be considered. 

8.3    Required Skills.

1. Working knowledge of healthcare claim and encounter processing.
2. Experience working with clearinghouses and/or health plans for claim or encounter submission, acknowledgement, rejection and correction processes.
3. Working knowledge of applicable healthcare EDI transaction sets including 837, 277, and 999 transactions.
4. Demonstrated ability to analyze encounter or claim rejections, identify trends or recurring issues, and research appropriate solutions.
5. Demonstrated ability to troubleshoot non-routine processing issues and determine when escalation is necessary.
6. Strong computer skills, including proficiency with Microsoft Excel.
7. Strong organizational skills and demonstrated ability to manage recurring production responsibilities while simultaneously managing technical or analytical assignments.
8. Exceptional attention to detail and commitment to data accuracy.
9. Ability to interpret technical specifications, follow established procedures, and document processes clearly.

8.4    Preferred Skills.

1. Experience with EZ-CAP or similar managed care claims administration system.
2. Experience creating, maintaining, or modifying healthcare EDI file mappings
3. Experience with EZ-EDI 837 Mapping Tool or similar EDI mapping software.
4. Familiarity with SQL/T-SQL for data research, validation, or troubleshooting.
5. Experience testing and implementing EDI changes or new trading partner configurations.
6. Managed care encounter submission experience

The pay range for this position at commencement of employment is expected to be reasonably between $33.02 and $38.85. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.