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 the RCS customer base for operational and reimbursement efficiency.  Maintenance and support of the company’s electronic eligibility verification service will be a primary responsibility. Direct collaboration with Client Engagement, Operations, Product Management, product engineers, Project Management, EDI division, Marketing, payers and clients is expected, requiring strong interpersonal and communication skills. 

Key Responsibilities:

• 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.
• Perform eligibility verification services implementation tasks, including client specific insurance plan code mappings, ensuring setup is accurate with respect to insurance plans, EDI payer connections and other required parameters.
• Manage and administer provider enrollment for eligibility on behalf of clients, collaborating directly with EDI division, business partners, Client Engagement and clients on payer specific progress.
• Proactively assess electronic eligibility opportunities across clients, executing upon immediate opportunities as warranted through collaboration with Client Engagement and Operations.
• Resolve eligibility transactional support events for internal and external clients by means of leveraging internal and payer resources, while further orchestrating communication and corrective activities.
• Provide continuous maintenance and management of new and evolving insurance plans pertinent to the revenue cycle, to ensure successful eligibility verification, insurance plan code mapping, claim population, submission, and adjudication. Maintenance includes but is not limited to conducting appropriate research to apply updates to claim address, payer ID, claim type, and naming conventions.
• Provide subject matter expertise to Client Engagement, clients, Product Management and Operations on, eligibility transaction edits and processing, acting as a liaison with product engineers and EDI division.
• Proactively assess healthcare billing regulations, insurance company initiatives, and applicable compliance items through payer and industry publications, facilitating informative communication across Client Engagement, Operations, clients, Product Management, and Marketing as applicable.
• Actively participate in the Company’s monthly Insurance Committee meeting and other internal Product Management meetings, ensuring that the RCS division’s interests are appropriately represented, while further ensuring applicable meeting detail is communicated across the division.
• Other duties as assigned.   

Education / Experience:

• Associate’s degree in healthcare, business or equivalent experience.
• Professional with strong communication, analytical, and time management skills.
• Detail oriented with strong organizational and multi-tasking skills.
• Ability to assess task priorities and work independently.
• Proficient in Microsoft Office applications, with advanced Excel skills considered a plus.
• Experience with medical billing and eligibility transactions (e.g., ANSI 270/271) considered a plus.