Payer Operations & Intelligence Specialist

United States·Middleburg Heightsmid

Other

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Quick Summary

Key Responsibilities

Independently manage and oversee provider EDI enrollment for electronic claims, remittance, and eligibility on behalf of clients, collaborating directly with internal departments to ensure accuracy,

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Responsibilities

~2 min read

→Independently manage and oversee provider EDI enrollment for electronic claims, remittance, and eligibility on behalf of clients, collaborating directly with internal departments to ensure accuracy, compliance, and timely implementation.
→Analyze and maintain insurance plan configurations, including eligibility verification logic, plan code mapping, claim population, submission workflows, and adjudication processes.
→Evaluate and communicate changes to payer requirements, regulations, and the impact of these changes on the billing operations to internal stakeholders and clients in a clear and actionable manner.
→Investigate and resolve complex transactional issues related to claims, remittance, eligibility, and claim status, exercising independent judgment to determine appropriate solutions.
→Identify opportunities to improve workflows, reduce errors, and enhance reimbursement outcomes through data-driven analysis and process improvement initiatives.Implement necessary updates and solutions within the payer configurations for transaction processing.
→Validate daily claim and remittance processing against established controls, identify discrepancies, and take corrective action as needed.
→Maintain the company’s electronic eligibility verification service and associated insurance plan code mappings by assessing eligibility response and billing requirements, collaborating on such with product engineers, Client Engagement, Operations and clients to enhance system functionality and performance.
→Provide subject matter expertise to Client Engagement, Operations and clients on EDI transaction edits (e.g., 270/271, 837, 835), and processing, collaborating with the EDI division to ensure optimal processing.
→Represent the RCS division in the Company’s monthly Insurance Committee Meeting and other cross-functional meetings, contributing insights and recommendations that influence business decisions ensuring divisional interests are appropriately represented.
→Other duties as assigned.

Associate’s degree in healthcare administration, business administration, or equivalent experience with a preference for a four-year bachelor’s degree;
Experience in healthcare revenue cycle, insurance billing and/or EDI transactions is preferred;
Proficient with Microsoft Excel and Word;
Experience managing multiple complex projects and priorities in a fast-paced, evolving environment;
Demonstrated ability to exercise independent judgment and make decisions affecting operational outcomes.

Strong analytical, critical thinking, and problem-solving skills;
Excellent interpersonal, communication, and cross-functional collaboration skills;
High attention to detail with a strong focus on accuracy and process improvement;