Programmer
Company: Community Health Group
Location: Chula Vista
Posted on: May 13, 2022
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Job Description:
EEO1: Technician POSITION SUMMARY The EDI Programmer's primary
responsibilities include all processes and duties that encompass
encounter data. The Encounter Data Analyst role is to plan, design,
implement, and test the encounter data processes as well as
generate, review, analyze, and submit all encounter data and Risk
Adjustment Process System (RAPS) for each of Community Health
Group's (CHG) programs and quality initiatives. This position will
serve as the lead in managing each encounter data process;
including the reporting and tracking of each submission, ensuring
data integrity for each submission, and that all regulatory and
system updates are implemented efficiently. This role will
proactively monitor all regulatory encounter data sites and work
closely with EDI and Claims staff to ensure all data is accounted
for which will maximize CHG's revenue. COMPLIANCE WITH REGULATIONS:
Work closely with all departments necessary to ensure that the
processes, programs, and services are accomplished in a timely and
efficient manner in accordance with CHG policies and procedures and
in compliance with applicable state and federal regulations
including CMS and/or Medicare Part D), and DHCS. RESPONSIBILITIES
Performs analysis related to solution design, development, testing,
maintenance, and support for EDI interfaces and systems, both to
and from the CHG's trading partners and core administrative payer
systems, with duties including but not limited to: Monitoring and
maintaining EDI exchanges and transaction processing and
maintaining the accuracy of production healthcare EDI transactions
and processes Serving as the primary point of contact in resolving
issues related to production EDI transactions related to claims,
payments, enrollment, provider data, real-time transactions,
clearinghouse activities, and other proprietary EDI formats Serving
as a primary point of contact to develop all ad-hoc reports relate
to EDI and Encounter data using SQL or related tools Attend and
participate in all encounter data related conferences, workgroups,
and webinars Serving as subject matter expert in new encounter data
regulations and quality measurements Configuring and accurately
maintaining CHG EDI applications that allow healthcare providers to
send and receive EDI transactions Gathering, documenting, and
analyzing requirements and combining user information with
knowledge of CHG systems and healthcare partners Diagnosing
problems with EDI production processes and working with other
technical and/or business resources to resolve issues Auditing data
to ensure the accuracy of information supplied to/from providers
and trading partners Analyzes and responds to inquiries regarding
initial EDI setups and issues related to EDI enrollment, claims
processing, payment inquiries, and clearinghouse activities, with
duties including but not limited to: Configuring required EDI
components for healthcare-related transactions Providing immediate
responses by researching and reconciling EDI transactional
inquiries, errors, and discrepancies Working with trading partners
to resolve issues related to EDI transactions Researching and
resolving EDI errors and internal and external escalations
regarding EDI related issues Identifying errors and escalating
complex issues to higher-level for assistance and review Responding
to sub-contractors and governmental entity inquiries Assists with
operational strategic objectives by analyzing business processes
and functions, ensures compliance of CAQH CORE Operating Rules,
HIPAA, and X12 standards and guidelines, gathers data and evaluates
input and output requirements and formats to formulate and
implement recommended solutions, with duties including but not
limited to: Analyzing and interpreting regulatory requirements and
policy and operational changes from various governmental entities,
such as the Department of Health Care Services (DHCS), Department
of Managed Health Care (DMHC), and Centers for Medicare and
Medicaid Services (CMS), and making recommendations and
implementing business and system requirements according to these
specifications Monitoring subcontractors encounter data to ensure
completeness, accuracy, reasonability, and timeliness prior to
submission to DHCS and in accordance with DHCS guidelines
Collaborating with developers and supporting EDI maps to ensure
compliance with business requirements Analyzing EDI
implementations, recommending improvements to processes, and
coordinating with trading partners to resolve issues Providing
support during and after implementation of healthcare electronic
data interchange applications Monitoring EDI file processing and
performing tests and troubleshooting problems to resolve all
transaction file issues and providing support to internal and
external stakeholders Maintaining knowledge of HIPAA EDI protocols
prepares all encounter data related reports and diagrams, and
maintains companion guides and other supporting documentation by
collecting, analyzing, and summarizing information and trends, with
duties including but not limited to: Developing and maintaining
documentation of EDI requirements and specifications Tracking EDI
activity and monitoring batch processes to identify and address
issues as they arise and reporting levels of activity to management
using key established metrics Supporting cost-benefit analysis,
impact analysis, and assessment for strategic operational projects
and policy and operational changes Performing analysis of CHG core
systems and data and fulfilling reporting needs for projects
Providing organization-wide support and acting as a resource on
reporting standards Maintaining documents for operational
procedures according to HIPAA standards and regulatory guidelines
Diagnosing problems with EDI processes and working with other
technical and business resources to resolve issues related to
producing documentation Ability to calculate Risk Score and
expertise in Risk Adjustment System (RAPS) Other duties as
assigned. Education: Bachelor's Degree in Computer Science,
Information Systems, or a Bachelor's Degree with equivalent
experience Experience/Skills: Working knowledge of the followings:
HIPAA transaction sets: 820, 834, 274, 270/271, 276/277, 277CA,
835, 837 P/I MAO-001, MAO-002, MAO-004, EVR Risk Adjustment Process
System (RAPS) DHCS pharmacy encounter data NCPDP File CMS pharmacy
encounter data PDE file Working knowledge of formal testing
methodology, the principles and practices of test plan development
and execution, and documentation of test results Working knowledge
of current technology transmissions and receipt methods and the
requirements of electronic data submissions Working knowledge of
software product lifecycle management, from defining requirements
to implementation Working knowledge of EDI mapping software and
intermediate SQL Skills Working knowledge of CAQH CORE Operating
Rules Working knowledge of medical billing and health care data
interfaces Working knowledge of and proficiency with Windows-based
PC systems and Microsoft Word, Excel, and Outlook Some knowledge of
Medi-Cal and Medicare programs Some knowledge of research,
analysis, and reporting methods Some knowledge of the principles
and practices of project management Ability to manage multiple
projects simultaneously, organize work, maintain accurate records,
respond to changing priorities, and achieve goals and timelines
Ability to work collaboratively with individuals at all levels in a
matrix organization while supporting multiple stakeholders Ability
to work collaboratively and productively with internal and external
entities in order to achieve efficient and timely solutions Ability
to collect, interpret and evaluate data, identify solutions,
project consequences of recommendations, and prepare written
reports Ability to perform technical and non-technical
troubleshooting and diagnose and resolve problems efficiently and
effectively Ability to translate data into understandable
information and deliver solutions that improve business processes
Ability to assist with the development and translation of business
requirements; Ability to demonstrate flexibility and creativity,
identify improvements to existing practices, and effectively adapt
to change Ability to interpret and apply rules, regulations,
policies, procedures, and guides Ability to act as an EDI resource
to staff and trading partners Ability to ensure confidentiality and
privacy on all external communication Ability to work independently
with minimal supervision and as a member of a team. Physical
Requirements: Minimum 30 lb. Lifting. May be required to work
evenings and/or weekends. Employment Type: Full Time Years
Experience: 3 - 5 years Bonus/Commission: No
Keywords: Community Health Group, Chula Vista , Programmer, IT / Software / Systems , Chula Vista, California
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