Payer Operations & Intelligence Specialist

Summary:  

The Payer Operations & Intelligence Specialist role is integral to ensuring all payer EDI transactions, edits and tools are appropriately maximized across the Revenue Cycle Services (“RCS”) division. The role is part of a tactical team that maintains a strong knowledge of the Company’s complete claim, remittance, eligibility and claim status capabilities, ensuring each is effectively deployed, maintained and supported across RCS clients for operational and reimbursement efficiency.  Proactive monitoring of payer and industry happenings is also expected to ensure company awareness of the ever-evolving payer billing and reimbursement landscape. Direct collaboration with Client Engagement, Operations, EDI division, Marketing, payers, clients, Project Management and Product Management is expected, requiring strong interpersonal and communication skills. 

Key Responsibilities:

• Manage and administer provider EDI enrollment for electronic claims, remittance and eligibility on behalf of clients, collaborating directly with Client Engagement, Operations, clients and EDI division as necessary.
• Provide continuous maintenance and management of new and evolving insurance plans to ensure successful eligibility verification, insurance plan code mapping, claim population, submission, and adjudication.
• Provide subject matter expertise to Client Engagement, Operations and clients on EDI transaction edits and processing, collaborating with the EDI division to ensure optimal processing.
• Proactively assess healthcare billing regulations, insurance company notices, and applicable compliance items through payer and industry publications, facilitating informative communication across Client Engagement, Operations, Marketing and clients as applicable.
• Validate daily claim and remittance processing according to established controls, raising awareness and corrective action as applicable.
• 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.
• Resolve claim, remittance, eligibility and claim status transactional support incidents as brought forward by internal and external clients.
• Actively participate in the Company’s monthly Insurance Committee meeting and other internal Product Management meetings, ensuring divisional interests are appropriately represented.

Education / Experience:

• Associates or above degree in healthcare, business or equivalent experience.
• Experience in healthcare revenue cycle, insurance billing and/or electronic data interchange (EDI) transactions (e.g., 270/271, 837/835) considered a plus.
• Proficient with Microsoft Excel and Word.

• Strong analytical and problem-solving skills.
• Ability to independently assess task priorities and work independently.
• Strong interpersonal and communication skills.