Patient Access and EDI Supervisor

Description

The Patient Access and EDI Supervisor oversees the demographic data capture, eligibility and insurance verification, and EDI processes. This leadership role is critical in optimizing revenue cycle processes, ensuring compliance, and improving overall operational efficiency.  This role will ensure the smooth and accurate exchange of electronic healthcare data, including claims, remittances, eligibility inquiries, and other transactions between our organization and external stakeholders such as insurance payers, healthcare providers, clearinghouses and vendors. 

The ideal candidate will have extensive experience in revenue cycle management within healthcare, with a strong focus on electronic data interchange and eligibility verification processes, a data driven mindset leveraging technology to identify trends and a proven track record of process improvement.

Leadership and Oversight:

• Direct and manage the eligibility and insurance verification and EDI teams, ensuring alignment with organizational goals and objectives
• Demonstrate leadership through cooperative interactions such as problem-solving, excellent written/verbal communication, and customer focus
• Present as a role model for conflict management and resolution
• Maintain personal contact with subordinates to ensure understanding of all assignments
• Ensure adequate staffing and equipment needs for the responsible business units
• Ensure staff is cross trained to provide backup and relief
• Provide leadership support to other areas as needed

Process Optimization:

• Continuously evaluate and improve processes, develop and implement best practices to enhance efficiency, accuracy and compliance
• Work closely with IT and business teams to implement solutions that align with revenue cycle goals and healthcare regulations (e.g., HIPAA, ANSI X12 standards)

Eligibility and Verification Management:

• Oversee the daily operations of eligibility verification processes to ensure timely and accurate determination of patient insurance coverage 
• Monitor translation of hospital data capture to ensure accurate claim delivery for timely adjudication in accordance with payor guidelines
• Oversee, in conjunction with external partners, the vetting, cross-walking and/or correcting of automated electronic demographic data and accurate posting of non-automated records
• Business Owner/Subject Matter Expert in RICA

EDI Management:

• Oversee the daily operations of EDI workflows related to electronic and paper claim submissions, remittance advice, eligibility verification, electronic funds transfers and other revenue cycle processes
• Ensure all EDI transactions are transmitted accurately and in a timely manner between the organization and external parties, including payers, clearinghouses, and providers
• Understand and document appropriate Network and File Transfer operations
• Monitor and manage EDI transaction volumes, identifying and resolving any transaction errors, failures, or delays
• Troubleshoot EDI issues, collaborating with internal teams (e.g., IT, billing, coding) and external partners to resolve data discrepancies
• Ensure that all EDI transactions are compliant with relevant regulatory requirements, including HIPAA and payer-specific guidelines
• Stay updated on industry changes, new EDI standards (e.g., ICD-10, ANSI X12 updates), and payer-specific requirements to ensure continued compliance and system compatibility

Patient Registration and Demographic Data Management:

• Oversee patient registration processes to ensure accurate and complete demographic data was captured at the time-of-service entry
• Monitor and resolve discrepancies in patient demographic data, ensuring the accuracy and integrity of all records
• Collaborate with cross-functional teams to ensure accurate data flow from patient registration to billing and EDI processes
• Identify opportunities for improving data capture processes, reducing errors, and enhancing overall data quality
• Ensure demographic data updates are timely and consistent with patient eligibility and insurance verification

Performance Metrics and Quality Assurance:

• Establish key performance indicators (KPIs) to monitor departmental performance, identify areas for improvement, and drive accountability
• Assist with the design of quality measures for each major process establishment or change
• Monitor adherence to Service Level Agreements

Reporting & Analysis

• Develop and maintain reports and dashboards to track key performance indicators (KPIs) such as claim rejection rates,