Manager of EDI, Eligibility, and Capitation
EDI Staffing - Long Beach, CA
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 Position Overview: The Manager of EDI, Eligibility, and Capitation will be responsible for the day-to-day management of electronic data interchange (EDI) systems, eligibility verification, and capitation processes within the MSOThis position supports accurate and timely data exchange between the MSO, payors, and provider networks, ensuring proper handling of member eligibility, claims, and capitation paymentsThe Manager will oversee a team of specialists, troubleshooting issues and collaborating with internal and external partners to ensure efficient operationsThis role is crucial to maintaining compliance with full-risk Medicare Advantage value-based contracts and enhancing the MSO's data management capabilities Key Responsibilities: 1EDI Management Oversee the daily operations of EDI systems, ensuring the accurate transmission of claims, capitation, eligibility verification, and enrollment data (837, 834, 835, 270/271 transactions)Ensure seamless integration between EDI systems and other internal/external systems such as practice management, claims processing, and electronic health records (EHR)Identify and resolve EDI errors and transaction discrepancies by coordinating with IT teams, payors, and providersSupport continuous improvements in EDI workflows to enhance data exchange efficiency and accuracy2Eligibility Management Manage the daily processes for eligibility verification, ensuring accurate and timely verification of member eligibility across the MSO's provider networkEnsure eligibility data is loaded and verified correctly from payors into the MSO's systems, maintaining data integrityTroubleshoot and resolve eligibility discrepancies with providers and payors to ensure smooth operations and prevent interruptions in member servicesSupport efforts to automate eligibility verification and reduce administrative burden3Capitation Management Oversee the calculation and processing of capitation payments, ensuring accuracy in provider compensation based on member attribution and risk scoresMonitor capitation agreements to ensure alignment with full-risk Medicare Advantage contracts, ensuring timely payment reconciliationWork with the finance team to investigate and resolve discrepancies in capitation payments, ensuring providers are compensated accuratelyAssist in generating capitation reports to provide insights into trends and potential issues4Compliance and Reporting Ensure all EDI, eligibility, and capitation processes comply with relevant regulations, including HIPAA and CMS guidelines for Medicare AdvantageSupport the preparation of reports on EDI, eligibility, and capitation operations, providing insights into performance, areas for improvement, and compliance adherenceStay informed of changes in regulatory requirements affecting EDI, eligibility, and capitation processes, implementing adjustments as needed5Cross-Functional Collaboration Collaborate with Operations, IT, Finance, and Provider Network teams to ensure data integrity and streamline EDI, eligibility, and capitation processesServe as a liaison between the MSO, payors, and providers to resolve operational issues related to data exchange, member eligibility, and provider paymentsCoordinate with external partners to optimize data transmission protocols and address issues in data reconciliation6Team Leadership and Development Supervise a team of EDI, eligibility, and capitation specialists, providing guidance, training, and performance managementFoster a culture of continuous improvement and innovation, encouraging team members to develop solutions for operational efficiency and accuracyEnsure appropriate staffing levels and provide ongoing training to keep the team current with industry trends and regulatory requirements7System Improvement and Innovation Identify opportunities to improve the efficiency and accuracy of EDI, eligibility, and capitation systems through automation and system enhancementsWork with IT and other stakeholders to implement technology solutions that improve data integration and reporting capabilitiesManage relationships with third-party vendors to ensure SLAs are met and systems function optimally Qualifications: Education: Bachelor's degree in Information Technology, Healthcare Administration, Business, or a related field requiredExperience: Minimum of 5 years of experience in EDI, eligibility, or capitation management within healthcareStrong experience with healthcare EDI transactions, eligibility verification, and capitation processes, particularly in a Medicare Advantage environmentProven ability to troubleshoot and resolve data discrepancies and operational issues in healthcare systemsLeadership experience with supervising teams and managing day-to-day operational workflowsTechnical Skills: Familiarity with EDI systems, data exchange tools, and healthcare management platforms (e.g., clearinghouses, payor systems, and EHRs)Proficiency in SQL, XML, and other data formats commonly used in electronic data exchangeExperience with claims processing and eligibility systems, with knowledge of industry standards (HIPAA, ASC X12)Leadership and Management: Strong problem-solving skills with the ability to lead a team and handle complex operational issuesExcellent communication and interpersonal skills for effective collaboration with internal teams, providers, and payorsAbility to manage multiple projects, prioritize tasks, and maintain focus on key objectivesPreferred Qualifications: Experience in a managed service organization (MSO), Independent Practice Association (IPA), or with Medicare Advantage full-risk contractsFamiliarity with value-based care models and risk adjustment practicesWork Environment: Office-based with the possibility of remote work flexibilityOccasional travel to provider sites or industry conferences may be requiredCompensation: $105,000.00 -120,000.00 per Year Comprehensive benefits package including health, dental, vision, 401(k), and paid time off
Created: 2024-10-11