Principal Business Systems Analyst Claims EDI

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Principal Business Systems Analyst – Claims EDI is responsible for solving cross-functional organizational information problems through identification and presentation of business and technical specifications based on customer and business needs, industry best practices and available technology. The incumbent for this role will work across the organization to define the functional, usability, reliability, performance and support requirements of a system, serving as a business subject matter expert for EDI Healthcare Claims and Electronic Remittance Advice (837/835), providing a link between the technical and business views of the system to ensure the solutions being developed will satisfy the needs of the business.

Amount of Travel Required: 5-10 %

Work Schedule: Travel; with Program Manager, Medicare D-SNP Enrollment work protracted and irregular hours and evening meetings, or work unusual hours for meeting attendance or participation in specific projects or programs.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

The following duties are expected to be performed for both the Medicare, Medicaid and any new business units:

•    Responsible for Claims, Claim Payments and EOP Domain 

•    Partners with operational claims and claims payment SME’s to translate business requirements into technical requirements

•    Responsible for creation and maintenance of companion guides

•    Participate in new or existing projects to implement new or modified EDI capabilities 

•    Responsible for identifying impacts to EDI

•    Responsible for drafting the EDI Business and Technical Project Requirements

•    Responsible for EDI Operational Readiness and contributing into Project level operational readiness

•    Contributes to test planning and test case generation

•    Monitors Project level SDLC to ensure that coding changes are tested and then promoted to production

•    Maintain EDI documentation

•    Share EDI documentation with relevant parties

•    Participates in business discussions to act as SMEs

•    Monitor, track and understand state and federal regulatory impacts to EDI and the 837I, P, D, and 835 transaction sets

•    Assists troubleshooting L2 support requests

•    Provides analytical support for systems projects, including business function support for large, complex, enterprise-wide transformation initiatives, data and system migrations, business area process transformations or improvement projects, and product installations.

•    Consults with business to identify and document current operational procedures, problems, system input and output requirements, data scope, functional usage, formatting, user screen layout design, workflows and security requirements.

•    Leads system requirements, user stories definition, design, testing, training and implementation support. Applies use of tools to define and document requirements.

•    Writes and maintains functional specifications for new or modified business systems.

•    Consults with technical, architecture teams to design and develop automated business solutions

•     Communicates business requirements and technical specifications to technical team.

•    Assists business in the creation of user documentation, instructions, and procedures.

•    Documents and monitors post-implementation issues and coordinates through resolution.

•    Develops and/or reviews departmental business system requirements and business systems design documents, customer acceptance test plans, and post-implementation plans.

•    Works with external technology partners in implementing new capabilities, systems enhancements  and technology.

•    Understands application development and works directly with software developers

•    Analyzes data that specifically supports the membership and premium payment business area

•    Provides analysis of efficiencies related to system enhancements/automation.

•    Documents Test Acceptance Criteria for Stories, Test Strategy, Test Plans, Test Results

•    Executes system, functional testing.

•    Leads user acceptance testing.

POSITION QUALIFICATIONS 

Competency Statements

Autonomy - Ability to work independently with minimal supervision.

•    Analytical Skills - Ability to use thinking and reasoning to solve a problem.

•    Technical Aptitude - Ability to comprehend complex technical topics and specialized information.

•    Systems Analysis - Ability to determine how a system should work and how changes in conditions, operations, and the environment will affect outcomes.

•    Business Acumen - Ability to grasp and understand business concepts and issues.

•    Decision Making - Ability to make critical decisions while following company procedures.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education: 

•    Bachelor's Degree (four-year college or technical school) Required, Field of Study: Information Systems, Finance/Accounting, Business or other technical-analytic field.

•    Or any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

Experience: 

•    Proven experience working as an EDI Analyst or in a similar role

•    7+ years working with Health Insurance or Health Care related data X12 EDI, FHIR, and other structured JSON, XML, or proprietary formats

•    7+ years working on Medicare/Medicaid claims and ERAs

•    Experience with implementing new EDI transactions and adjusting existing ones for new rules (example: Medicare Delinquency Rules)

•    Experience with Health Insurance or Health Care related data X12 EDI, FHIR, and other structured JSON, XML, or proprietary formats 

•    Experienced with WEDI SNP Editing

•    Strong knowledge of EDI protocols and standards, such as ANSI X12, EDIFACT, XML, and AS2. (Specifically, the 837 and 835 IGs and X12 CARC/RARC Code sets)

•    10 plus years of experience in business system analysis, software development, data analytics on large enterprise-wide transformation initiatives

•    7 plus years working in a large health plan environment

Computer Skills:

•    Advanced in Office 365 suite of products, Project, Visio, Requirements Management Tools, 

•    Agile Team Collaboration Tools 

Certifications & Licenses:

•    Business System Analysis Professional Certifications (IIBA or equivalent) , Business Owner

•    Product Owner, Product Manager Certifications, Data Analytics Certification or Training 

Other Requirements:

•    Ability to develop functional requirements and documentation for technical staff.

•    Ability to develop data process modeling/mapping. Ability to develop system test plans.

•    Possess a very high degree of subject matter expertise in HIPAA, EDI x12 transactions, WEDI SNP editing, which may require expertise in benefits, claims adjudication, provider or employer contract administration, member and provider demographic management

•    Demonstrated experience in creation of business process diagrams, data flow diagrams, non-complex data models.

•    Ability to drive positive results in difficult circumstances with ability to cope with rapid change. Possess an understanding of health industry data elements, and understanding  of how elements are used within departmental processes.

•    Ability to present business analytical concepts or design to senior leadership

•    Excellent analytical and problem-solving skills, with the ability to identify and troubleshoot issues related to data communication and system integration.

•    Excellent communication and interpersonal skills, with the ability to work effectively with cross-functional teams and external partners.