Lead EDI Specialist

2 weeks ago

Pittsburgh, United States Pantherx Specialty Llc Full time
7,000 Diseases - 500 Treatments - 1 Rare Pharmacy

PANTHERx is the nation’s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.

If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don’t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.

We are seeking team members who:

Are inspired and compassionate problem solvers;

Produce high quality work;

Thrive in the excitement of the ever-challenging environment of modern medicine; and

Are committed to achieving superior health outcomes for people living with rare and devastating diseases.

At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.

Join the PANTHERx team, and define your own RxARE future in healthcare

Location: Pittsburgh, PA; remote.

Classification: Exempt

Status: Full-Time

Reports to: Director, Revenue Reconciliation

Purpose:

The Lead EDI Specialist provides technical support to staff and ensures company EDI strategy is aligned to support the teams. This role enters new insurance & addendums into the system in a timely efficient manner. This position identifies, analyzes, and resolves provider claims submission issues. This role acts as a liaison between multiple groups i.e. the insurance plan, claims, providers, and departments within the company to effectively resolve claims issues.

Responsibilities:
  • Assists in testing and onboarding new providers for successful transmission of their files.
  • Imports and exports EDI files and document information in their respective logs.
  • Documents corrective actions and resolution of carrier rejection reports.
  • Identifies payers and works closely with Wellsky and Payer EDI teams to successfully bill medical claims via 837 processes.
  • Creates and documents tickets where system issues are reported.
  • Works closely with EDI Manager to resolve issues and implement new EDI processes.
  • Sets up Claim Center and maintains in accordance with company policies.
  • Loads fee schedules based on contract or letter of agreement requirements.
  • Updates Medicare quarterly to reflect changes in codes, fees, or coverage from the Medicare fee schedule.
  • Troubleshoots electronic claims submissions to ensure correct payment per terms of contract.
  • Reviews and maintains applicable licenses for Veteran’s Affair programs.
  • Manages payer site passwords for Medicaid and Commercial payers for Revenue Cycle Management and Finance.
  • Other duties as assign
Required Qualifications:
  • Associate degree in business administration, Health Care Administration, related field, or equivalent experience.
  • Experience in specialty pharmacy, pharmacy and medical claims automation, subject matter expert in pricing table loading and maintenance.
  • Ability to read and interpret payer contract language and provider manuals.
  • Understanding of payment methodologies based on WAC, AWP, ASP, etc.
  • Demonstrate proficiency in conducting QA and testing on EDI applications (5 years preferred).
  • Strong understanding of healthcare claims processing – claims, provider, eligibility.
  • 4+ years of combined claims processing and data analysis or related insurance experience. Lead or supervisory experience preferred.

Work Environment:

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Physical Demands:

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function of the job.

Benefits:

Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too

Equal Opportunity:

PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.

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