EDI Administrator

The purpose of this job is to support the Electronic Data Interchange (EDI) program, through handling compliance for multiple jurisdictions across multiple lines of business by ensuring performance standards are met, efficiency of reporting and data quality. This role provides support to the internal Claims team, along with other analytical and project-based support functions within the department in support of business and company goals.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Supports regulatory reporting, research, and compliance data management

• Collects, organizes, and analyzes workers’ compensation data including claim data, financial data, and other relevant information based upon requests.

• Assists in the completion of data calls or targeted audits by collecting and preparing information.

• Completes various types of research on a regular basis for changes in regulations and as requested by external auditors.

• Documents and maintains workflows and procedures on the various components of EDI reporting.

• Maintains current knowledge of policies, procedures, and reporting operations across Medicare, reinsurance ceding, FROI/SROI, and IDC reporting to support compliance standards.

• Provides subject matter expertise in areas including FROI/SROI and Medicare Section 111 reporting.

• Complies with regulatory requirements and company rules.

• Stays updated on industry communications and changes in legislation to support changes regarding Medicare and other regulatory changes to communicate information to stakeholders and support changes.

• Assists with special projects assigned by management.

Analyzes EDI data to identify areas of non-compliance

• Reconciles daily FROI/SROI diaries to ensure timely and successful transmission of claims data to various reporting agencies.

• Completes various forms of transactional tracking to ensure efficiency, timeliness and accuracy of reporting.

• Supports Medicare Secondary Payer Act processes and compliance with all state regulations.

• Analyzes and validates data at the time of submission, corrects errors and troubleshoots issues with documentation or vendors.

• Notifies and works with appropriate Claims Team Members to resolve errors.

• Identifies workflow and system gaps and reports to management.

• Maintains and manages EDI documentation of workflows to ensure accuracy and consistency with stakeholders to address data discrepancies.

• Handles errors to ensure accurate and timely reporting of EDI transactions.

• Completes various forms of transactional tracking to ensure compliance goals are met.

• Distributes reports to management according to department procedures and policies.

Manages daily inbound and outbound data flow of EDI traffic

• Reconciles daily FROI/SROI diaries to ensure timely and successful transmission of claims data to various reporting agencies (including Medicare and rating bureaus).

• Analyzes and validates data at the time of submission to ensure accuracy and completeness, and coordinates with stakeholders to address data discrepancies.

• Partners with the Claims team to resolve errors and provide support on EDI processes, protocols, and system usage.

• Monitors EDI queue and assists in clearing backlog diaries, emails, and issues as needed in support of the Supervisor.

• Supports monthly and quarterly Section 111 CMS Reporting as needed.

• Distributes reports to appropriate teams according to department procedures and policies.

Identifies opportunities for continuous improvement

• Identifies workflow and system gaps and recommends changes for process improvement.

• Assists in conducting internal audits to identify areas of non-compliance and report to Audit & Compliance Manager to rectify issues.

• Identifies data integrity discrepancies and participates in correcting/implementing solutions to improve overall data quality.

• Develops and maintains accurate up-to-date records of compliance workflows. Maintains and manages EDI documentation (including Medicare).

• Participates in the process to develop and implement change proposals in response to regulatory compliance, proactive improvement, and any other workflow improvements to improve compliance.

Participates and supports trainings to educate Claims Team on regulatory processes

• Helps with training Claims Team Members on processes, state regulations, policy changes, reporting requirements and other departmental needs related to Medicare processes.

• Supports with the creation and maintenance of comprehensive training materials/curriculums.

• Schedules training sessions, tracks attendance and reports on training and attendance results.

• Assists with facilitating training classes to various workers’ compensation claims audiences.

Collaborates with internal teams, technology teams, and state agencies to manage EDI processes

• Collaborates with internal teams, external stakeholders, and regulatory agencies to facilitate data collection, resolve data-related queries and ensure effective communication of the EDI process.

• Provides support during the implementation phase of EDI projects to assist in development of initial testing plans and participate in user acceptance testing.

• Collaborate with IT Teams, EDI vendor, and other State or Federal agencies to identify areas of opportunity and resolve issues.

• Assists in training incoming staff and acts as a resource for colleagues in the department to answer questions and solve complex problems.

SUPERVISORY RESPONSIBILITIES

This role does not have supervisory responsibilities

EDUCATION AND EXPERIENCE

High school diploma or GED required; some college coursework towards an associate or bachelor’s degree  preferred. Minimum of 2+ years’ claims insurance (or closely related) experience required.   Good familiarity with claims electronic data interchange (EDI) is highly desired.

CERTIFICATES, LICENSES, REGISTRATIONS

None required. Associate in Reinsurance and/or Medicare Secondary Payer Accreditation (MSPA) preferred.

KNOWLEDGE AND SKILLS

• Must be proficient in Microsoft Office (Excel, Word, PowerPoint and Outlook) and with compliance management software and tools.

• Must possess intermediate to advanced data entry skills with the ability to learn enterprise and department specific applications.

• Good understanding of insurance claims principles and practices.

• Strong analytical, problem-solving, detail oriented, attention to detail, organization skills required.

• Excellent communication (verbal/written) and interpersonal skills required.  

• Must have the ability to:

  • Interpret complex laws and compliance measures.

  • Develop and implement effective compliance strategies.

  • Complete complex tasks, assignments, and defined processes under limited supervision.

PHYSICAL REQUIREMENTS 

Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear. 

WORK ENVIRONMENT 

This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment.

This description is a general statement of essential job functions and responsibilities.

The position may include other duties as assigned.

We are currently not offering employment sponsorship for this opportunity

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