EDI Analyst

Job Opportunity At Pinnacle Claims Management

If you're looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we're looking for you. At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees. As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn't a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee's life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options. With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees' job satisfaction and success. Compensation: $61,719.12 - $80, 234.24 with a rich benefits package that includes profit-sharing.

Job Description Summary

This position reports to the Vice President of IT. The EDI Analyst manages, plans, and leads the daily activities for electronic data interchange to ensure proper handling and timely processing of electronic data files. The position coordinates file transfers, upgrades and changes between systems, vendors, carriers, and clients. The position provides research and analysis services to business areas and assists in planning and delivery of the technical solutions to support Western Growers Assurance Trust and Pinnacle Claims Management, Inc. business strategies. Additionally, this position will be responsible for the administrative duties surrounding customer facing web portals such as PERC, WERC, OPIS and Health View.

Qualifications

• Bachelor's degree in Management Information Systems (MIS), Computer Science, Healthcare Administration, related field, or three (3) years equivalent business experience. • Experience working with EDI transactions, ideally within the healthcare industry. Familiarity with IT applications for healthcare operations/service. • Exceptional communication skills, with the ability to effectively collaborate cross-functionally with internal teams, vendors, carriers, and clients. • Proven ability to approach complex issues with a service-oriented mindset, focusing on collective solutions and driving team results. • Expertise in HIPAA regulations, eligibility and enrollment processes, and relevant IT applications within the healthcare industry. • Advanced proficiency in full-cycle implementation of EDI transactions, including mapping, data analysis, and troubleshooting. • Strong experience with EDI software/tools and platforms; understanding of data flow and integration between systems. • Background in information technology implementation, production operations, and vendor management. • Demonstrated ability to take ownership of issues and deliver consistent, high-quality results. • Experience managing projects from initiation through completion, adhering to deadlines, scope, and quality standards. • Strong attention to detail, ensuring high levels of accuracy and consistency in all aspects of work.

Duties and Responsibilities

Electronic Data Exchange • Maintain day-to-day operations and oversight of EDI Applications. • Monitor and reconcile EDI eligibility transmission, receipt, and processing of EDI transactions within the Eligibility and Enrollment department. • Reconcile benefit transactions between inbound and outbound 834 files. • Ensure billing accuracy as a product of processing EDI eligibility and benefit transactions through systematic and manual adjustments. • Provide timely communication of all EDI production issues and resolution strategies to carriers. • Identify and gather key stakeholders for each relevant production issue on EDI to assess the issue(s), make sure key resources and business associates are aware and informed of the production problem, while collaborating with the key stakeholder team to implement the appropriate fix.

Business Efficiency • Proactively explore opportunities to improve the quality, efficiency, and performance of business processes. • Establish the priority of identified issues and opportunities and analyze them to determine the detailed activities, resources, and costs associated with their implementation. • Understand business functions and develop a communications plan for all stakeholders and trading partners that need to be aware of pending changes. Assist in the process of developing test plans, test cases, test scripts, and data sets for developed applications and their integration to other systems. • Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses. • Create and document a minimum of one new Standard Operating Procedure (SOP) annually. • Initiate at least one process improvement or innovation annually.

Customer Support • Maintain day-to-day operations and oversight of WERC/PERC, and other customer facing web portals. • Collaborate with clients, vendors, and different operations and development teams in resolution of all production issues to ensure a stable operating environment and deliver results consistent with Service Level Agreements. • Communicate with other operational departments to ensure smooth integration of new client data files for both WGAT and PCMI. • Provide timely and effective Customer Service to clients or vendors for requests, inquiries, or issues concerning enrollment and/or billing items on their account. • Work with cross-functional teams to implement initiatives from conceptualization to completion, while adhering to system development life cycle principles. • Work closely with all departments to plan and schedule testing and necessary data requirements for projects that require EDIs testing. • Assist with all technical needs, including account refreshes, security assignments, job scheduling, and research items.

Other • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results. • Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet. • Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data. • Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit). • All other duties as assigned.