SQA EDI Specialist

Signature Performance

Position Purpose:

Responsible for verifying healthcare software's protocols, features, and functionality as well as characterizing system performance through testing, documentation, configuration and collaboration.

Organization:

This position reports to the Director of PMO.

Essential Job Functions include the following. Other duties may be assigned.

  • Perform analysis related to solution design, development, testing, maintenance, and support for EDI interfaces and systems, both to and from trading partners and core administrative payer/payee systems
  • Serve as a point of contact in resolving issues related to EDI transactions related to claims, payments, enrollment, provider data, real-time transactions, clearinghouse activities, and other proprietary EDI formats
  • Analyze and interpret regulatory requirements and policy and operational changes from various governmental entities related to HIPAA and related EDI transactions and make recommendations and implement business and system requirements according to these specifications.
  • Serve as a subject matter expert in software testing and validation
  • Perform EDI Mapping for 837, 277CA, 834, 835, TA1, 999, 820, NCPDP D.0
  • Develop and execute test scripts related to X12 Transmission
  • Conducts QA and Testing of applications
  • Develop and execute Test scripts related to X12 Transmission
  • Develop and execute Test scripts related to TriZetto Facets®
  • Develop and execute Test scripts related to third party business rules applications.
  • Track and document testing results
  • Assist in the setup and testing of users/new Trading Partner relationship/Standards/Envelope and full cycle testing
  • Provide technical support during and after implementation for healthcare electronic data interchange applications
  • Respond to inquiries regarding EDI issues with encounter claims and trading partner activities
  • Management of catalog of EDI document types such as 837, 277CA, 834, 835, TA1, 999, 820, NCPDP D.0
  • Maintaining detailed documentation and process flow of all EDI processes
  • Identify and facilitate issues with partner data mapping from onset through completion
  • Researching and resolving EDI errors and internal and external escalations regarding EDI related issues
  • Identifying errors and escalating complex issues to higher-level for assistance and review
  • Maintaining documents for operational procedures according to HIPAA standards and regulatory guidelines
  • Diagnosing problems with software and system processes and working with other technical and business resources to resolve issues related to producing documentation
  • Developing and maintaining documentation of software and EDI requirements and specifications
  • Identifies, recommends and implements process improvements in support of healthcare software systems
  • Troubleshoot EDI document processing errors and work with trading partners directly to resolve in a timely matter
  • Conducts analysis of EDI transactions and is responsible for documentation and reports
  • Collaborate with EDI partners to resolve transmission problems.
  • 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
  • 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
  • Triages incoming EDI issues thru monitoring
  • Ability to communicate effectively with technical and business staff
  • Support internal resources to resolve issues, answer questions, and retransmit EDI documents when necessary
  • Work with end users to ensure user acceptance testing is thorough and complete
  • Employees should be able to work independently with minimal supervision.
  • Knowledge of Agile Methodology
  • Assisting with reporting issues.
  • Conduct audits in partnership with the internal and external stakeholders and conduct config analysis by reviewing configuration set-up and identifying root cause of findings
  • Complete configuration requests as back up to coworkers and counterparts
  • Attend configuration staff meetings and educate/inform the Configuration Team
  • Identify process improvement opportunities to improve accuracy and timeliness (i.e., automation, turn around time, etc.)
  • Assist with Internal quality control points (peer reviews, auditing, testing, verification and validation)
  • Serves as SME to assist coworkers and counterparts in coaching and developing knowledge (knowledge transfer)
  • Participate in configuration requirement gatherings for new processes
  • Maintains departmental quality and production goals and objectives.
  • Performs other duties as assigned.

Knowledge & Experience:

  • Working knowledge of the followings:
    • HIPAA transaction sets: 820, 834, 274, 270/271, 276/277, 277CA, 835, 837 P/I
    • MAO-001, MAO-002, MAO-004, EVR
    • Risk Adjustment Process System (RAPS)
    • DHCS pharmacy encounter data NCPDP File
    • CMS pharmacy encounter data PDE file
  • High degree of business and technical knowledge with significant practical experience in HIPAA X12 EDI Transactions
  • Expert in developing and executing test scripts related to X12 EDI Transmission
  • Expert in EDI mapping for 837, 277CA, 834, 835, TA1, 999, 820, NCPDP D.0
  • Demonstrated proficiency in conducting QA and testing on EDI applications
  • High degree of business and technical knowledge with significant practical experience in HIPAA X12 EDI Transactions
  • Experience in creating and managing catalog of EDI document types such as 837, 277CA, 834, 835, TA1, 999, 820, NCPDP D.0 (3 years)
  • Experience setting up users/new Trading Partner relationship/Standards/Envelope and full cycle testing
  • Proven experience in processing and monitoring all inbound and outbound X12 transactions (3 years)
  • Experience in collaborating with EDI partners to resolve transmission problems (2 years)
  • Knowledge of Agile Methodology
  • Skilled in creating and deploying SQL queries
  • Ability to effectively communicate and collaborate with diverse internal and external stakeholder groups and individuals.
  • Able to collect, research, and understand diverse information, and translate it into clear and concise written requirements.
  • Able to plan, prioritize, and balance the need for direction with self-motivated efforts.
  • Strong interpersonal skills
  • Working knowledge of formal testing methodology, the principles and practices of test plan development and execution, and documentation of test results
  • Working knowledge of current technology transmissions and receipt methods and the requirements of electronic data submissions
  • Working knowledge of software product lifecycle management, from defining requirements to implementation
  • Working knowledge of CAQH CORE Operating Rules
  • Working knowledge of medical billing and health care data interfaces
  • Working knowledge of common healthcare administrative terminology
  • Working knowledge of and proficiency with Windows-based PC systems and Microsoft Word, Excel, Visio, Teams and Outlook
  • Some knowledge of research, analysis, and reporting methods
  • Some knowledge of the principles and practices of project management
  • Ability to manage multiple projects simultaneously, organize work, maintain accurate records, respond to changing priorities, and achieve goals and timelines
  • Ability to work collaboratively with individuals at all levels in a matrix organization while supporting multiple stakeholders
  • Ability to work collaboratively and productively with internal and external entities in order to achieve efficient and timely solutions
  • Ability to collect, interpret and evaluate data, identify solutions, project consequences of recommendations, and prepare written reports
  • Ability to perform technical and non-technical troubleshooting and diagnose and resolve problems efficiently and effectively
  • Ability to translate data into understandable information and deliver solutions that improve business processes
  • Ability to assist with the development and translation of business requirements.
  • Ability to demonstrate flexibility and creativity, identify improvements to existing practices, and effectively adapt to change
  • Ability to interpret and apply rules, regulations, policies, procedures, and guides
  • Ability to act as an EDI resource to staff and trading partners.
  • Ability to ensure confidentiality and privacy on all external communication.
  • Ability to work independently with minimal supervision and as a member of a team.

Preferred:

  • Bachelor's degree in a healthcare or comparable field.
  • Prior Experience or degree in a healthcare related field.
  • Proficiency in using various Web-based and other research sources and tools
  • Knowledge of claims adjudication and payment

General Areas of Accountability:

Must conduct business and personal affairs in a manner that is always a credit to the company. Must maintain a good credit rating while employed with the company. Applicants must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Visa sponsorship is not available for this position.

Certain positions may be subject to additional background screening depending on client need and access to certain systems.

Machines and Equipment:

The incumbent must be able to effectively operate the current computer system, telephone system, and other office machines such as copier and fax machines.

Physical Activity:

The incumbent must be able to finger, grasp, feel, see, sit, hear, and speak. This position is sedentary in nature with minimal lifting requirements.

WORKING CONDITIONS:

The incumbent works in an office environment that is not substantially exposed to adverse environmental conditions such as heat, cold, or extreme noise. Routine periods of being on the phone utilizing a headset, sitting and data keying are required.

Remote Eligibility: This position is full-time remote eligible. Eligibility is determined by Management or Human Resources.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified

Job ID: 9021

Posted 13 days ago

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