Healthcare Analyst


On Site
Full Time



Job Details

Summary: The Analyst acts as the primary liaison between IT and the operational departments within the organization. This position functions in a trusted advisor role. This position will primarily support the Claims functional area of the organization with a strong focus on Healthcare EDI data sets. This includes submissions to the NYS Medicaid, Managed Care, and CMS for Medicare claims.

Duties and Responsibilities: Other duties may be assigned.
1. Testing, including the creation of test scenarios, test data and understanding of outcomes
2. Responsibilities include but are not limited to knowledge of claims editing and adjudication, product regulations and encounter transactions / submission/ recovery.
3. Keeps current with industry trends and state/federal compliance initiatives
4. Supports clients and coworkers
5. Communicates internally and externally with all levels of employees including senior management
6. Identifies issues and facilitates problem resolution
7. Serves as technical and subject matter expert for claims data and claim processing life cycle
8. Analyzes and queries data; has knowledge of the EDI files.
9. Data mapping, including the creation of file specifications, production, and test EDI files.
10. Research new programs and billing rules and communicates his finding to the development team.
11. Testing, including the creation of test scenarios, test data and understanding of outcomes. Provides in-depth analysis to resolve any potential issues prior to new updates being pushed to production.
12. Manages the technical efforts associated with implementing complex EDI trading partners.
13. Participates in implementation meetings with clients and vendors when necessary.
14. Provide HIPAA-compliant guidance and billing guidance to trading partners requesting additional information about industry standards and requirements.
15. Performs routine and ad hoc analysis of various facets of EDI processing including but not limited to system performance, claim turnaround times, data mapping, and claim volumes.
16. Builds and maintains positive working relationships with internal colleagues (including IT, Sales and Marketing, Implementation, Operations and Billing) and external contacts.
17. Attends onsite and offsite meetings with clients, payer representatives or state agencies.
18. Provides coverage for other team members as needed; some on-call support duties may be required. Performs demos when necessary.
19. Assists with hiring and training of new employees. Prepares and conducts internal training as well as client trainings via Go To Meeting or remotely.
20. Communicates potential solutions to management. Implements solutions.
21. Implements process improvements to enhance the efficiency of the EDI processes.
22. Performs other related duties as assigned.

Minimum 2-3 years previous experience as an Analyst
Must have some SQL experience
Health Care Industry experience
Strong data analytics skills
Previous experience and business knowledge with health care claims adjudication systems, including the end-to-end life cycle of a claim, EDI 837 and 835 transactions
Knowledge of Claims Billing (procedure codes, modifiers, diagnoses) a plus
Knowledge of health care benefits and product offerings including NY State of Health exchange plans, Medicaid, Medicare, Dual, Child Health Plus and Managed Long Term Care programs a plus

Education/Experience: Bachelor's Degree or Higher.

Computer Skills: Advanced knowledge Microsoft Office particularly Excel as well as EDI files (835, 837, 277, 277CA, 999, etc.). Must have hands on SQL experience.


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