Revenue Cycle EDI Specialist

Description

SEES Group is looking for a Revenue Cycle EDI Specialist to join out Franklin team!

SEES Group operates multi-specialty medical practices and ambulatory surgery centers across the Southeastern United States and US Territories.  Working with community-based Optometrists and Physicians, we provide patients with the highest quality medical and surgical eye care they need close to home. Our organization’s shared values include integrity, respect, service, compassion, and excellence!  

SEES Group recognizes that our employees are our most important asset. Because of this, we strive continuously to encourage our staff to live their healthiest life by providing benefits, perks, resources, and programs to assist with managing both their physical and mental health. We offer access to an employee assistance program for those who may need mental health, legal, or financial assistance. Also, we are currently offering a quarterly “Stress Free Day” to full time staff members where employees can take a paid day off to focus on their own wellness and mental health. 

Aside from those fantastic benefits, we also offer medical, dental, and vision insurance; 7 paid holidays; employer paid life Insurance; a robust paid-time allotment; voluntary products such as short and long term disability coverage; and a 401k retirement plan with a generous employer match. We offer certification programs to clinical staff to assist in professional development. Lastly, we offer employee service awards to our tenured staff members to recognize our appreciation for their continued service to our organization.

The Payment Applications Manager supports SEES Management, LLC’s goals, values and philosophy by exhibiting the following behaviors: excellence, quality service, commitment and accountability. As a member of the SEES Management, LLC team, performance includes demonstration of the following accountabilities: communication, teamwork and job knowledge.
POSITION SUMMARY
The EDI Specialist is responsible for working EDI transactions and ERA files, including reconciling carrier submissions, edits and rejection reports. This position is responsible for handling all correspondence related to an insurance or patient account, contacting insurance carriers, patients and other facilities as needed to get produce clean claims and receive maximum payment on accounts and identify issues or changes to achieve client profitability.
ESSENTIAL FUNCTIONS:
This position is responsible for ensuring that all electronic claims submitted through SEES clearinghouses are accepted by the clearinghouse and insurance plans. The EDI Specialist is responsible for making corrections on rejected claims and successfully resubmitting the claims.
• Import or Export, research and interpret ANSI X12 files coming from various sources. Formats include: 837I, 837P, 835, 834, 278 and 999.
• Communicate with payers to get clarification on rejections, denials and eligibility requirements.
• Creates reports of common entry errors to perform frequent audits of data loaded to ensure accuracy.
• Validate all billing through claim scrubbers before processing to the clearinghouse.
• Troubleshoot EDI document processing errors and work with trading partners directly to resolve in a timely matter
• Track day-to-day EDI & batch processes to identify and address problems as they arise reporting levels of activity using key established metrics for senior management
• Conducts analysis of EDI transactions and is responsible for documentation and reports
• Education to stay current with all CPT and ICD-10 early updates, as well as, drug policies per insurance carrier.
• Ability to research and resolve accounts appearing on Rejected Claims Reports
• Identify any issues or trends and bring them to the attention of management team
• Ability to educate in a collaboratively manner with team members who are responsible for inputting patient demographic in an effort to reduce rejections.
• Assist in coordinating the design, testing and generation of new management reports as business requirements dictate. Partners with business areas to define solutions and resolve technical issues.
• Develops and administers documentation of projects, recommendations, and implementation procedures. Communicates project outcomes in a clear, effective, and timely manner to necessary parties in the business area and other customer areas.
• Conducts QA and testing on EDI applications.
• Responsible for setting up users/new Trading Partner relationship/Standards/Envelope and full cycle testing
• Management of catalogue of EDI document types such as 837, 277CA, 834, 835, TA1, 999, 820, NCPDP D.0
• Maintain detailed documentation and process flow of all EDI processes
• Effectively communicate issues and needs with internal business partners, external vendors, and healthcare providers.
• Develops and maintains cross walking and validation rules for file exchanges.
• Completes all required compliance training.
* * * * Job Description * * * *
• Duties and responsibilities may be added, deleted, or changed at any time at the discretion of management, formally or informally, either verbally or in writing.
KNOWLEDGE, SKILLS, & ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Detailed knowledge of physician practice management, physician contracting, and revenue cycle management.
• Demonstrated skills to manage in a multiple facility environment, with the ability to hire and develop effective managers.
• Ability to analyze and interpret complex data while working in an organization with various key stake holders.
• Ability to prepare and research comprehensive reports and ability to communicate them clearly.
• Knowledge of healthcare administration and practice philosophy, policies and operating procedures.
• Knowledge of governmental regulations and reimbursement requirements.
• Skill in exercising initiative, judgment, problem solving, decision-making. Good computer skills including advanced used of standard office programs
• High level of knowledge with deductibles, contractual adjustment, insurance plans, and procedures
• Detail oriented with strong organizational and follow-up skills
• Good interpersonal and customer service skills
• Good computer skills
• Responsible for adapting and communicating to changing insurance regulations
• Ability to speak, read, and write in English
• Ability to effectively communicate both orally and in writing
• Ability to operate standard office equipment
• Ability to concentrate, think, and learn
• Ability to hear, see, sit, stoop, kneel, crouch, reach, lift, push, and pull.
EDUCATION AND/OR EXPERIENCE
Bachelor’s degree in Business Administration or Finance is preferred; a minimum of five (5) years’ revenue cycle management experience is preferred; previous leadership experience is required; and/or equivalent education or experience in job related activities is required.
WORK ENVIRONMENT
Position is in an office setting that involves everyday risks or discomforts requiring normal safety precautions. Position involves long periods of sitting and working on a computer.

Qualifications