EDI CLAIMS PROCESSOR II

The EDI Claims Processing Coordinator II is responsible to provide primary supports to EZ-EDI configuration during system upgrade and enhancement, coordinate workflows in relates to EDI file transmission, provide training to other EDI team members, create and maintain EDI procedural manual.  Routine duties and responsibilities may include EDI data validation and monitoring of the daily auto-processing and auto-posting activities, detect and correct errors, reconcile data discrepancies, and to communicate with Trading Partners regarding EDI data rejects and follow up with resubmission activities.  This position also assists in health plan audits and other special projects as needed. 

This position requires high level of critical thinking skills and excellent analytical and problem-solving skills. Candidate is also required to have strong written and verbal communication skills to allow for effective communication at any level; able to juggle multiple projects to ensure follow-through, and work in a detail oriented manner.

ESSENTIAL JOB FUNCTIONS:

• Responsible to provide primary supports to EZCAP & EZ-EDI configuration and enhancement for system maintenance, including testing of new functions and monitoring of auto data flows prior to and during system maintenance and upgrade.
• Work closely with MSO Operating System Architects and MSO Configuration Analysts to coordinate workflows in relates to EDI file transmission and data validation.
• Responsible to create and maintain a detail EDI Claims Procedural manual.
• Responsible to provide training and information updates to other EDI team members.
• Responsible to monitor the daily automatic inload, validation, and posting activities in EZ-EDI application for the HIPPA 837 EDI files received through the NEMS SFTP.
• Responsible to reconcile inloaded records with submitted records to ensure data accuracy, and to communicate with Trading Partners for data errors and file rejects information, and follow through with resubmission activities.
• Responsible to generate 277CA/999/997 Claims Acknowledgement report for Trading Partners after each EDI file is posted into EZCAP successfully.
• Communicate with database team member to update new/changed provider records and service codes in EZCAP as seen in the submitted EDI files.
• Catalog and maintain an EDI processing log for each individual Trading Partner that submits EDI file, to record and reconcile validation error for each submitted file.
• Provide information in response to the request of EDI submitter, patient, physician, insurance company or co-worker as appropriate.
• Assist in Health Plan and/or DHCS audits and other special projects as needed.
• Assist in developing reports to improve EDI workflow processes and the end to end claims processing cycle and reconciliation needs.
• Maintain and improve skill sets by taking necessary training in SQL and reporting
• Performs other job duties as required by manager/supervisor.

QUALIFICATIONS:
 

• Bachelor’s Degree in Systems Analysis, Computer Programming, or other relevant area of study or bachelor’s degree in General Education and one year experience in health care data exchange or equivalent combination of education and experience.
• Two (2) years’ experience in health insurance claims billing and/or claims processing and examination.
• Two (2) years’ experience in handling health care Electronic Data Interchange activities in HIPAA formatted files.
• Must have strong analytical and problem solving skills.
• Strong written and verbal communication skills to allow for effective communication at any level.
• Demonstrated ability to use Microsoft Access, Excel, or Crystal Reports as troubleshooting tools;
• Ability to self-manage in a detail oriented environment.
• Good organization and prioritization skills, outstanding in time management.
• Ability to reliably and consistently deliver quality work product on target dates.
• Knowledge of healthcare standard code sets and claim forms preferred.
• Experience with computer programming a plus.
• Knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455) and DHCS/Medi-Cal guidelines a plus.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluent in other languages are an asset.

STATUS:

• This is an FLSA NON-exempt position.
• This is not an OSHA high-risk position.