EDI & Claims Operations Analyst

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

📋 Description

• Oversee the status of claims across clearinghouses and payer systems to confirm successful transmission, receipt, and processing of claims.

• Examine extensive claim populations to pinpoint trends, obstacles, acceptance challenges, and payer-specific workflow issues.

• Investigate claims that are rejected, unacknowledged, delayed, or stalled to identify root causes.

• Collaborate with Billing Operations, Insurance Verification, Denials Management, Coding, Configuration, Engineering, and Automation teams to resolve claim processing challenges.

• Identify potential for automating manual claim status workflows to enhance operational efficiency.

• Act as a subject matter expert on clearinghouse operations, payer connectivity, claim submission workflows, EDI transactions, and claim status processes.

• Research specific payer requirements, acceptance criteria, rejection trends, and status behaviors.

• Formulate recommendations for workflow enhancements aimed at increasing claim acceptance rates and minimizing downstream denials.

• Monitor and analyze claim status performance metrics and relay insights to operational leadership.

• Support the implementation and optimization of automated solutions concerning claim status management and payer communications.

• Develop process documentation, job aids, and operational guidance to facilitate standardized workflows.

• Assist with managing escalations and making complex claim routing decisions.

• Work together with internal and external stakeholders to identify systemic issues and implement lasting corrective measures.

⛳️ Requirements

• A bachelor's degree or an equivalent combination of education and experience.

• Over 4 years of experience in healthcare revenue cycle management.

• Proficiency in claim submission, claim status, claim acceptance/rejection management, or EDI operations.

• Strong comprehension of healthcare claims workflows and payer processing systems.

• Experience in researching and resolving issues related to claim transmission, acceptance, or rejection.

• Advanced skills in Microsoft Excel or Google Sheets, including data analysis and reporting capabilities.

• Excellent analytical, investigative, and problem-solving skills.

• Ability to work autonomously and drive issues to resolution across various teams.

• Exceptional communication and stakeholder management skills.

• Preferred: Experience with clearinghouses like Change Healthcare, Waystar, Experian, Availity, or similar platforms.

• Preferred: Knowledge of EDI healthcare transactions, including 837 claims, 835 remittances, and claim status transactions.

• Preferred: Background in supporting healthcare automation initiatives or workflow optimization projects.

• Preferred: Familiarity with analytical tools such as Snowflake, Power BI, Tableau, SQL, or similar platforms.

• Preferred: Understanding of payer configuration, payer enrollment, or electronic claims routing.

• Preferred: Experience in high-volume healthcare billing environments.

🏝️ Benefits

• Comprehensive medical, dental, vision, life, and disability plans for eligible employees and their dependents.

• Complimentary testing for Natera employees and their immediate family members.

• Fertility care benefits available.

• Leave for pregnancy and baby bonding.

• 401(k) benefits offered.

• Commuter benefits provided.

• Employee referral program in place.