EDI & Process Improvement Specialist

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Requirements:

• Five years of experience in claims adjusting, claims special programs, or related experience, including at least three years of experience with state EDI requirements
• Knowledge of state specific reporting requirements preferred
• Knowledge in understanding of the EDI Tables and implementation guides at state level
• Strong knowledge of workers compensation claims processes, claims handling, and workflows
• Good knowledge of computers
• Strong investigative and problem-solving abilities
• Ability to distill and communicate complex issues for technical and non-technical audience
• Ability to multi-task and prioritize deadlines
• Strong organizational, written and verbal communication skills
• Strong attention to detail
• Strong customer service skills
• Ability to adhere to high standards of professional conduct and code of ethics

Responsibilities:

• Maintains high data quality standards across all projects and initiatives as related to EDI
• Leads the process of ensuring all state specific requirements are appropriately tracked and implemented with vendor partner and within claims platform
• Performs thorough verification and validation of data entries to ensure accuracy and completeness
• Identifies, tracks, and rectifies discrepancies, inconsistencies, and errors in datasets through careful analysis and investigation
• Utilizes data management tools to conduct data verification processes efficiently
• Documents and reports findings, issues, and resolutions
• Maintains daily rejection and error reports to stay informed on the efficiency, timeliness, and accuracy of the claims EDI program
• Solves reporting errors or state criticisms and respond to inquiries regarding reporting matters
• Stays updated on industry trends, emerging technologies, and best practices related to data verification and quality assurance
• Proactively monitors proposed changes from states to their EDI process or order of items to be submitted. Ensures implementation of necessary updates for EMC to remain in compliance
• Collaborates with internal leadership and IT to monitor timely implementation of required system changes/upgrades, and vendor partners to facilitate data collection, resolve data-related queries and ensure effective use of vendors, communicating updates throughout the process
• Monitors reporting activity and assists in ensuring the timely completion of action items
• Monitors states where vendor support is not possible based on state requirements
• Serves as the primary contact between EMC and vendor as audits occur. Recommends best practices to ensure alignment with state requirements as identified
• Researches and tracks untimely filings resulting in penalties in multiple jurisdictions
• Identifies opportunities for process improvement to enhance the efficiency and effectiveness of the EDI workflow
• Ensures compliance with data reporting requirements set by regulatory agencies, ensures adherence to specific data instructions and standards, and timely submissions
• Collects, organizes, and analyzes data to report to claims team leadership
• Researches EDI compliance standards and maintains compliance workflows for all jurisdictions, where applicable
• Provides training and support to internal users on processes, protocols, proper utilization/efficiency implementation, and systems
• Participates in continuous improvement and efficiency initiatives aimed at optimizing data verification processes and workflows
• Maintains relationships with the claims team members and jurisdictional parties to ensure compliance and prompt responses to penalties imposed, where applicable
• Partners with Quality Assurance and WC Claims leadership to determine if issues persist and if targeted or large scale training is appropriate
• Supports claim goals by leading, assisting and/or owning a process, special projects and assignments as directed by Claims Leadership