Overview
Remote
Depends on Experience
Contract - Independent
Contract - W2
Contract - 12 Month(s)
Skills
Electronic Data Interchange (EDI)
Service-Level Agreements (SLA)
Regulatory Reporting
Insurance Industry
Reporting Requirements
Healthcare
Job Details
Healthcare EDI Analyst (Encounters & Claims)
12 months contract
Fully Remote Position
Overview
Seeking an experienced Healthcare EDI Analyst with strong knowledge of Encounter and Claims data within the healthcare/insurance industry. This role focuses on analyzing encounter data, ensuring compliance with CMS and State reporting requirements, and supporting new implementations and vendor oversight.
Key Responsibilities
- Compile, analyze, and validate Encounter and Claims data to meet Service Level Agreements (SLAs).
- Review and resolve encounter data rejections and data quality issues.
- Serve as a Subject Matter Expert (SME) for CMS and State Encounter reporting.
- Lead or support regulatory data projects related to claims encounters.
- Ensure data accuracy, compliance, and timely submissions to regulatory agencies.
- Develop and maintain reports, metrics, and dashboards for performance monitoring.
- Identify process gaps and recommend improvements for data accuracy and efficiency.
- Collaborate with IT, Claims, Enrollment, and other internal teams on encounter data processes.
- Support vendor management, including SLA oversight and compliance tracking.
- Participate in automation and process improvement initiatives for encounter functions.
Required Skills & Experience
- Strong healthcare/insurance industry background (required).
- Hands-on experience with Claims and Encounter data, CMS/State regulatory reporting, and EDI transactions (837, 835).
- Proficiency in SQL (SQL Server 2016+ preferred); strong data analysis and reporting skills.
- Knowledge of Edifecs (preferred) or similar EDI tools.
- Familiarity with CPT, ICD-9/10, HCPCS, and healthcare billing/coding.
- Understanding of managed care, claims processing, and reimbursement methodologies.
- Excellent communication, analytical, and problem-solving skills.
- Ability to work independently and collaboratively in a remote environment.
Preferred Qualifications
- Experience with 837O/MA EDS submissions to CMS or State agencies.
- Experience with 835 files and claims reconciliation processes.
- Prior work with vendor data oversight and regulatory compliance.
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