Sr Systems Analyst - Payer Health Plan (ACA & Medicare) - Remote

Veradigm Payer 

Veradigm understands that managed care organizations, pharmacy benefit managers (PBMs), insurance companies, health plans, and other payers need to balance controlling costs with the goal of providing the highest quality of care and optimizing health outcomes for their members.

Solutions from Veradigm Payers:

• Deliver insights to drive quality outcomes cost-effectively
• Improve efficiency for themselves, their providers, and their members through high-speed clinical data exchange
• Impact point-of-care decision making positively by integrating payer guidance and prior authorization management directly in each healthcare provider’s existing workflow

Job Summary

Join the Payer Health Plan Customer Support team as a Sr Systems Analyst working with enterprise customers of Veradigm Comprehensive Submissions Encounter Management Platform, proactively assisting them with post- sales installation, configuration, upgrade, troubleshooting and day to day operational management.

Responsibilities include taking a proactive leadership role working with the engineering team and customers to triage and resolve highly complex, technical, and application-related issues which impact product performance in customer-specific environments, or issues that directly hamper a broader customer adoption of Veradigm Comprehensive Submissions Encounter Management Platform. In addition to working with customers, the analyst will routinely partner with our development, engineering and sales engineering organizations to resolve support issues, document bugs, provide UAT on product builds, and ensure that new and newly upgraded server installations are successful.

This is a remote role.

What you will contribute:

• Support encounter data reporting processes for EDPS, and the EDGE server, including tracking, reporting, and resolving rejections.
• Conduct gap analysis and data validation, identifying possible issues in data submission and determining financial impact.
• Analyze and reconcile claims and encounter data which will include 837 EDI encounter files for EDPS, and Edge Server submission files.
• Perform research in the encounter management system and liaison with the CSSC Helpdesk for exception resolution.
• Be comfortable with raw data files in their native format and accessing these through various servers.
• Provide technical support to enterprise clients related to technical and operational aspects of the products.
• Partner with Product Support Engineers and development teams as necessary
• Assist development team with performance analysis and testing during release cycles for service packs, hot fixes etc.
• Answer email and phone requests for help from customers
• Collaborate in virtual teamwork with other Product Support staff
• Host online troubleshooting and investigation sessions on customer’s production environments
• Deliver a consistent, responsive and satisfying customer experience with each contact
• Collect all necessary problem details from customers to be able to effectively see the problem to resolution
• Successfully reproduce customer issues in a controlled test environment
• Follow standard operational procedures for case management
• Continuously improve troubleshooting skills, product expertise, and knowledge on related technical topics
• Update knowledge base / create reusable documents, originating from patterns observed during customer issue troubleshooting
• Perform ACA and MA Submissions for Clients
• Understand and keep track of CMS model changes which details about eligible Risk Adjustment codes (diagnosis, CPT, HCPCS, etc.,) for submissions.
• Review and understand periodic CMS software releases which impact both the ACA and MA submissions.
• Understand EDPS filtering logic which CMS uses for Risk Adjustment and/or Risk Score calculations.
• Monitor CMS data submission deadlines for both MA and ACA lines of business.

The ideal candidate will have:

Academic and Professional Qualifications:

· Bachelor’s Degree in Health IT/Informatics/Management Information Systems or related field required

Experience:

• 5+ years of professional experience in Risk Adjustment data management
• Understanding of claims data, encounter response files, 837 EDI encounter files, EDGE/MA billing & business rules as well as MA filtering logic for EDPS
• Experience with CMS Submissions Process and EDI transactions
• Excellent time management and organizational skills necessary
• Prior experience troubleshooting performance problems that may have many underlying causes such as Disk, Database, Network, Messaging and other platform / 3rd party solutions.
• Experience with managing product back end and webservices
• Ability to guide customers remotely through complex, multi-server deployments and upgrades for enterprise products
• Familiarity with at least one non-Windows operating system (such as Linux, HPUX, AIX)
• Familiarity with EDI Standards such as X12, EDIFACT, HL7, NCPDP and knowledge of HIPAA transactions.
• Knowledge of various network and internet technologies and communication protocols: TCP/IP, SFTP, HTTP, AS2, etc. highly desired.
• Prior knowledge of 837’s along with various loops and segments and an understanding of the requirements set forth by CMS for EDPS submission files
• Prior experience with ETL and Mapping
• Excellent working knowledge of SQL
• Very strong written and verbal skills.
• Knowledge in CMS model changes is a plus
• Knowledge of CMS Risk Score and Risk Adjustment methodologies is a plus.
• Knowledge of Medicaid is a plus and having a good understanding and work experience on the Medicaid is a great added value.

Travel Requirements:

· Will travel to Company head quarter for new hire orientation and if there are any specific training or customer meetings.

Working Arrangements:

· Monday through Friday or as defined by assignment requirements