EDI Business Analyst

About Pediatrica Health Group Inc.

Every day is a good day to prepare for a healthy tomorrow. Providing children and their families with equitable access to quality pediatric care to build a foundation for a lifetime of optimal health and wellness is what drives our team to deliver its best every day. It’s our purpose.

Offering focused care from tots to teens, our pediatric primary care providers and teams partner with families to foster good health and strong, thriving communities. Second-to-none medical staff and top-tier administrative professionals keep our practices running smoothly and make each patient experience the best we can offer.

Working in partnership with patients, families, and communities who put their trust in us for their care, we hold ourselves accountable to ensure equitable access to care, advocate to create impactful change, and continually learn and progress to create better outcomes and brighter futures. Together, we’re paving the way for kids to develop into healthy young adults. Rooted in these values, we continue to grow and serve. Are you ready to join us?

POSITION SUMMARY:

The EDI Business Analyst Specialist designs, implements, supports, and validates practice and provider constructs within the clearinghouse. This position includes monitoring of data feeds and related loads to ensure systemic risks are identified and corrected across all Pediatrica Health Group practices.

Success in this position includes assisting in the growth and maintenance of our clearinghouse solutions by researching industry changes and data sets, analyzing data trends, identifying areas of opportunity, and aiding in the implementation of these enhancements. Ideal candidates have a naturally analytical way of thinking, can quantitatively and qualitatively analyze information, are process-oriented, and enjoy research and team collaboration.

ESSENTIAL FUNCTIONS

Clearinghouse & EDI Operations

• Design, implement, support, and validate practice and provider constructs within the clearinghouse.
• Monitor data feeds and related loads; identify and correct systemic risks before they impact claims or revenue. Develop and maintain a professional relationship with the clearinghouse partner and their staff.
• Research industry changes and data sets, analyze data trends, and support the implementation of clearinghouse enhancements.

 Process Analysis & Optimization

• Work closely with RCM leadership and staff to evaluate business processes, anticipate requirements, identify improvement opportunities, and develop and implement optimization strategies.
• Stay current on the latest medical billing processes and guidelines to identify claim-editing, fee-schedule, and systemic changes for implementation.
• Perform gap and issue analyses, root-cause assessments, and resolution planning.
• Adapt policy-related documentation to requirements and conduct refinement analysis to ensure solutions meet business needs.

 Collaboration & Communication

• Conduct meetings and presentations to gather critical information, share ideas and findings, and effectively communicate insights and plans to cross-functional team members, with a focus on IT relationships.
• Create detailed reports and present data to stakeholders; influence stakeholders and work closely with them to determine acceptable solutions.

 Testing, Projects & Documentation

• Perform system integration testing and user acceptance testing (UAT).
• Assist with project management, including developing project plans and monitoring performance to ensure initiatives are prioritized based on business needs and requirements and that deliverables are on track for timely completion.
• Update, implement, and maintain department procedures and documentation.

 KNOWLEDGE, SKILLS & ABILITIES

• Deep knowledge and understanding of professional claims processing and adjudication in the healthcare and health insurance industry.
• Well-versed in r