Claims Management Analyst III

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the EDI (Electronic Data Interchange) trading partners and the network of clearinghouses to guarantee accurate and timely information exchange.

• Collaborate closely with Vendor Management to enhance and uphold the trading partner agreements with partners, focusing on cost optimization and service additions.

• Cultivate and maintain partnerships with trading partner account representatives.

• Manage the performance of trading partners, setting and monitoring service level agreements, regulatory obligations, and contractual metrics.

• Serve as a Subject Matter Expert (SME) across all departments regarding eBusiness-specific EDI transactions.

• Build, maintain, and utilize relationships to foster continuous improvements in the EDI business process.

• Deliver critical reporting and analysis of functional performance, while providing suggestions for enhancements, cost-saving initiatives, and process improvements.

• Evaluate and analyze the effectiveness and efficiency of current processes and systems, engaging in the development of solutions to enhance or further capitalize on these functions.

• Take part in estimating initiative budgets, developing business cases, and tracking benefits.

• Grasp the business strategy and lead eBusiness initiatives, collaborating with IT and other internal departments to automate functions.

• Understand the procedures for receiving claims, handling claim rejections and denials, claims payment methodologies, adjudication processing, and Encounters to foster synergy among IT and business teams.

• Contribute to and/or create user stories or provide guidance for user stories during sprint planning.

• Develop, document, and execute testing and validation as necessary.

• Maintain a comprehensive understanding of the company’s business and regulatory landscapes.

• Identify issues, risks, and opportunities for mitigation.

• Execute any additional job responsibilities as assigned.

⛳️ Requirements

• A Bachelor’s degree or equivalent relevant work experience is required.

• A minimum of five (5) years of experience in health care operations, specifically in insurance, managed care, or a related field is required.

• Advanced understanding of healthcare EDI files (837, 277CA, 999, 270/271, 276/277, etc.).

• Proficient computer skills.

• Proven exceptional communication skills (both verbal and written) and a high level of professionalism.

• Data analysis and trending capabilities, including experience in query writing.

• Familiarity with Claims IT processes and systems.

• Working knowledge of managed care and health claims processing.

• Ability to effectively engage with all management levels within the organization and across various organizational layers.

• Strong interpersonal, leadership, and relationship-building abilities.

• Decision-making and problem-solving capabilities.

• Capacity to work both independently and collaboratively within a team environment.

• Time management skills; adept at multitasking and prioritizing tasks.

• Keen attention to detail.

• Effective decision-making and problem-solving abilities.

• Strong critical thinking and listening skills.

🏝️ Benefits

• A substantial and comprehensive total rewards package.

• Potential for bonuses linked to company and individual performance.