Claims Manager EDI & Encounters

This Claims Manager EDI and Encounters oversees all aspects of the Electronic Data Interchange (EDI) and Epic Tapestry Encounters responsibilities encompassing a strong knowledge of standards, concepts, practices, and procedures within areas of healthcare, EDI X12 Specifications and HIPAA 5010 transactions. This position is accountable for the daily direction of the EDI Claims Specialists regarding prioritization of tasks and routine inquiries, monitoring production and encounter edits both from the payors and from CMS, inventory, and special projects, evaluates the quality assurance of the EDI data exchanges and encounter submissions, oversees testing of new functionality upgrades, and maintains a strong working relationship with Ecommerce vendor partners and payers while staying current with industry trends within the Ecommerce industry. Works closely with other departments inside and outside of Advocate Physician Partners to identify and correct root causes of quality problems and will provide senior leadership recommendations for enhancements and changes to applications, anticipating business challenges and regulatory issues. The Manager EDI and Encounters will develop new product/client implementation regarding managed care operational enhancements and strategic initiatives on behalf of the providers affiliated with Advocate Health Care and non-affiliated PHO’s. This includes evaluating the education and training protocols and recommending appropriate and timely updates as it relates to current and future trends in EDI/Encounter processing. Acts as a liaison between Advocate Physician Partners and internal/external auditors as it relates to the EDI claims process and encounter submissions. The incumbent will closely communicate with the Director of Claims and Coding Compliance keeping them informed of changes, resource constraints, and escalation of issues that will affect their respective area. This position requires comprehensive understanding of multiple business objectives, ability to meet multiple deadlines for encounter submission and the ability to lead in a highly competitive and ever-changing environment.

Major Responsibilities:

• Responsible in the development and implementation of procedures and standards to assure adherence to Advocate Physician Partners/AAH policies and procedures for system implementation and support for EDI and Encounters.  Recommends standards and configurations related to new products/enhancements by preparing written evaluations and assessments.

• Accountable for development/implementation of policies, procedures, standards of EDI and encounters and Prepares project plans, estimates schedules with resources required, identifies objectives and incorporates Advocate Health Care and IS strategies allowing projects to meet short and long-term goals.

• Manages the overall testing of the Claims Processing software as it relates to APP operations. Manages the testing of EDI claims files, ensuring the appropriate processing for claims reimbursement. This includes various software routines and algorithms that are used in the claims processing system-built logic or relating to the appropriate submission/resubmission of encounter files. Manages the testing of any new development and processes relating to EDI and encounter files.  Coordinates and leads testing processes with third parties to implement electronic claims/receipt submission. Develops comprehensive test plans.  Coordinates execution of tests.  Tracks and coordinates resolution of problems with teammates and vendors. Works closely with HIT Tapestry department to develop strategic planning and implement current and future enhancements of the software.

• Responsible, generates and communicates provider setup for 835 and newly contracted physician.  Works with clearinghouse to ensure providers are receiving appropriate explanation of benefits based on their 835/EFT set up between the clearinghouse and APP using the Tapestry system.

• Accountable for the monitoring and maintenance of EDI transaction and encounter file submissions document flow resulting in ongoing seamless flow of operation with analysis of changes in procedures, policy, and processing system to determine need for new or revised training material.

• Responsible to ensure and coordinate with Tapestry IT the setup of EDI related specifications, which includes but not limited to inbound/outbound 837 claims and encounter submission, 277-CA, 278, 999, 835 and maintains business rules related to EDI specifications for claims payments with the clearinghouse and/or scanning vendor.

• Maintains knowledge of current and future trends in managed care as it relates to APP business operations.  Stays aligned with the rapidly changing healthcare climate staying abreast of developments in the industry to expand understanding of relevant trends and issues.  Participates in CQI teams to develop protocols, guidelines and special projects in order to improve processes within the APP Managed Care and claims processing software environments.  Manages and coordinates large projects at multiple sites, within a team, or stand-alone projects with general direction.  Prepares, maintains and provides status reports on project plans. Tracks and coordinates schedules, equipment and resource requirements, assuring all project documentation is organized and complete. .

• Develop and manage work plans, testing guides, policies and procedures relating to process reengineering for multiple sites. The policies and procedures encompass operations effecting commercial, Medicare and Medicaid enrollees.

• Any and other duties as assigned in the planning, management and execution of the Encounter/EDI Processes

Licensure, Registration, and/or Certification Required:

• License/Registration/Certification: None Required

• Education Required: Bachelor's degree in health care administration or related field

Experience Required:

• 10 years' experience in health care, managed care, insurance or population health to include experience in a leadership role at least 3 years

Knowledge, Skills & Abilities Required:

• EDI/Encounter process management    
• Strong knowledge of claims processing
• Understanding/knowledge of ANSI File Formats and interpretation of format

• Claims processing software such as EPIC/GE/Burgess
• EFT/ERA implementation for provider offices and oversight of existing set ups
• Exchange of EDI File between EPH and payer
• Documentation of workflows and process improvement
• Problem solving skills
• Experience w Epic Tapestry a big plus

Physical Requirements and Working Conditions:

• This position is remote but may require some in person meetings.  Candidate would be expected to join in person/on site meetings as scheduled
• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.