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Company: Community Health Group
Location: Chula Vista
Posted on: May 13, 2022

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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