Sr EDI Specialist

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

***This position is work from home in California, with the potential for occasional in-person meetings.

Position Summary:

The Senior EDI Specialist is responsible for daily oversight and operation of EDI systems, customers/vendors. The Senior EDI Specialist will coordinate and execute practices and protocols to ensure data flows smoothly, without delay and without error between the trading partners as well as develop internal/external IT policies and standards. The Senior EDI Specialist will serve as the senior liaison to users, departments, customers and vendors by providing the expertise on all aspects of EDI services and provide EDI integration (mapping), data transmission set-up. The Senior EDI Specialist needs to be an in depth subject matter expert for EDI Business and Technical operations.

Responsibilities may include:
- Day-to-day support for all EDI questions and problems.
- Oversees vendor relationships including operational metrics.
- Creating and integrating maps and processes providing implementation and analytical support for, as well as participating in the design and implementation of new systems.
- Performs business support responsibilities, which production monitoring, file maintenance, ad hoc reporting and consultation with internal and external clients.
- Handles claims (837I, 837P) communicated over EDI including oversight of relationship with clearinghouses used to receive claims from providers and overseeing process of loading paid and unpaid claims into organization’s various systems.
- Runs Eligibility (834) process between Enrollment system, claim system, and trading partners.
- Oversees trading partner relationships including, monitoring EDI systems and analyzes data, transmission, and mapping errors and tracks and troubleshooting issues with affected trading partners.
- Runs processes related to CAQH CORE rules including 270/271, 276/277, 835/EFT, and other future EDI transactions.
- Runs Encounter Data System (EDS) process for submitting encounters to Medicare systems.
- Works with development SQL development staff to design and implement EDI solutions.
- Primary escalation point for managing issues related to EDI transactions.
- Supports various departments (Claims, Operations, Enrollment, etc.) as primary point of contact regarding EDI transactions.
- Performs data audits and quality control measures and creates reports to support compliance requirements.
- Creates and maintains accurate EDI maps between systems.
- Creates and maintains companion guides, workflow diagrams and documentation.
- Acts independently or as part of a team to solve technical problems and avoid crisis.

Minimum Qualifications:

- BS/BA degree or equivalent work experience.
- Knowledge of EDI standard formats (ANSI X12), TSQL experience (queries, stored procedures, views, etc.) including data analysis and process improvement, promotes teamwork and leads by example, while successfully collaborating across functions and departments.
- Unquestionable ethics & integrity is pertinent.
- Excellent judgment and decision making skills, customer-focused, with demonstrated experience and liability to be flexible with changing priorities, demands and requests.
- Demonstrated ability to identify root issues and resolve end-to-end and aptitude for gaining a thorough understanding of the business and actively applying it to individual work.

Preferred Qualifications:

- Broad understanding of health care insurance and claims processing, experience with healthcare related EDI transactions strongly preferred.

- Knowledge of EDI transaction sets used in managed care (such as 837p, 837i, 835, 277CA) strongly preferred.

- In-depth knowledge of EZCAP and experience with EZCAP modules related to claims, eligibility and authorizations strongly preferred.

- Ability to train and mentor junior staff members on EDI processes and best practices strongly preferred.

- In-depth experience with encounter data (such as validating, reconciling, ensuring meets both payer and regulatory requirements, rejections from payers) strongly preferred.