Medicare Advantage EDI Operations Specialist

1 week ago


Los Angeles, California, United States UCLA Health Full time

Medicare Advantage EDI Operations Specialist

UCLA Health is seeking a highly skilled EDI Operations Specialist to join our Medicare Advantage Operations team. As a key member of our team, you will be responsible for maintaining and running processes/jobs for electronic claims and other EDI transactions. This will involve working with external trading partners, transferring/loading data through secure channels, and testing files from new providers/trading partners.

Key Responsibilities:

  • Maintain and run processes/jobs for electronic claims and other EDI transactions
  • Work with external trading partners to ensure smooth data transfer
  • Test files from new providers/trading partners to ensure compliance
  • Coordinate business transactions for all HIPPA/CMS standard sets
  • Deliver operational efficiencies and meet claim data submission requirements

Requirements:

  • Bachelor's degree in computer science, information technology, business, or a related field
  • Five years of experience with CMS processes in a Medicare or managed care environment
  • Advanced proficiency with SQL, SSIS package, data visualization tools, and Microsoft Office
  • Knowledge of physician and facility billing practices, appropriate CPT coding initiatives, ICD-10 coding standards, and revenue/HCPCS coding
  • Extensive experience with claims encounter strategies and processes
  • Knowledge of claims payment methodologies, adjudication processing, and Federal encounter regulations
  • Knowledge of encounter regulatory reporting and compliance requirements
  • Previous vendor management experience
  • Ability to research and resolve encounter issues
  • Understanding of the health care model, capitation, and other managed care IPA and provider reimbursement methodologies
  • Excellent communication, interpersonal, analytical, and problem-resolutions skills
  • Ability to modify and adapt operational procedures to changing operational needs
  • Strong leadership, critical thinking, and prioritizing abilities
  • Ability to develop, implement, and evaluate methods and systems to improve efficiency
  • Ability to articulate ideas to both technical and non-technical staff

About UCLA Health:

UCLA Health is a world-renowned health system with four award-winning hospitals and more than 260 community clinics throughout Southern California. We are also home to the David Geffen School of Medicine, a highly respected leader in the development of breakthrough medical research and outstanding clinical professionals.

UCLA Health is an equal opportunity employer and welcomes all individuals without regard to race, sex, sexual orientation, gender identity, religion, national origin, or disabilities.


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