Job Description
Job Description
This position is a Subject Matter Expert for the HIPAA 837 Claim Intake and Encounter EDI transactions. This position will join a team of other EDI SMEs who are responsible for maintaining the day to day operations and integrity of the 837 Claim/Encounter transaction as well as support ongoing strategy and business development.
The candidate must have:
* Familiarity with HIPAA, Electronic Data Interchange, 837
Claim/Encounter details.
* Familiarity with X12 Transaction Guidelines and industry standards.
* Familiarity with EWM, ACAS, HRP and HMO claim intake/ adjudication processes.
* Familiarity with ICD-10, HCPCS, CPT and other medical
coding.
* Familiarity with Hospital, Professional and Dental claim
submission formats.
* Works with business and IT constituents across key functional areas/lines of business to understand potential project impact on the transaction, organization, align project work, and execute activities accordingly.
* Presents to internal/external customers, constituents and business partners, strong business as well as systems knowledge and can perform reasonability checks.
* Participates with external industry workgroups as Aetnas representative for 837/Encounter EDI transactions.
* Perform issue analysis by utilizing system information, business knowledge and industry transactional guidelines.
* Influences change or enhancements to business processes, policies and system infrastructure to improve information quality, availability and access.
* Develops and participates in presentation and consultation to existing and prospective customers, business partners and internal business areas on information services, capabilities and performance results.
* Proactively evaluates project activities, builds contingency plans, executes corrective action, and monitors issue resolution to mitigate risks such as scope and/or budget variances.
Required Qualifications
* 3-5 years related work experience.
* Familiarity with EDI.
* Familiarity with APLC - Agile and Waterfall.
* Proven track record meeting project dates.
* Excellent communication skills, both written and verbal.
* Ability to manage multiple priorities.
* Proven ability to affect change.
* Strong understanding of the healthcare industry and regulatory environment, including in-depth knowledge of medical and specialty products.
* Demonstrated ability to effectively coordinate multiple projects simultaneously.
* Experience communicating for impact.
* Experience maximizing work practices.
* Ability to turn data into information.
* Experience performing business information analysis.
* Experience providing E. Business support.
* Ability to perform Issue identification and analysis.
* Ability to assess risk.
* Familiarity with Microsoft SharePoint.
* Familiarity with Microsoft Word.
* Familiarity with TE Microsoft Excel.
Preferred Qualifications
* Creating Accountability
* Developing and Executing Strategy
* Driving a Culture of Compliance
Education
Bachelor's degree or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
This position is a Subject Matter Expert for the HIPAA 837 Claim Intake and Encounter EDI transactions. This position will join a team of other EDI SMEs who are responsible for maintaining the day to day operations and integrity of the 837 Claim/Encounter transaction as well as support ongoing strategy and business development.
The candidate must have:
* Familiarity with HIPAA, Electronic Data Interchange, 837
Claim/Encounter details.
* Familiarity with X12 Transaction Guidelines and industry standards.
* Familiarity with EWM, ACAS, HRP and HMO claim intake/ adjudication processes.
* Familiarity with ICD-10, HCPCS, CPT and other medical
coding.
* Familiarity with Hospital, Professional and Dental claim
submission formats.
* Works with business and IT constituents across key functional areas/lines of business to understand potential project impact on the transaction, organization, align project work, and execute activities accordingly.
* Presents to internal/external customers, constituents and business partners, strong business as well as systems knowledge and can perform reasonability checks.
* Participates with external industry workgroups as Aetnas representative for 837/Encounter EDI transactions.
* Perform issue analysis by utilizing system information, business knowledge and industry transactional guidelines.
* Influences change or enhancements to business processes, policies and system infrastructure to improve information quality, availability and access.
* Develops and participates in presentation and consultation to existing and prospective customers, business partners and internal business areas on information services, capabilities and performance results.
* Proactively evaluates project activities, builds contingency plans, executes corrective action, and monitors issue resolution to mitigate risks such as scope and/or budget variances.
Required Qualifications
* 3-5 years related work experience.
* Familiarity with EDI.
* Familiarity with APLC - Agile and Waterfall.
* Proven track record meeting project dates.
* Excellent communication skills, both written and verbal.
* Ability to manage multiple priorities.
* Proven ability to affect change.
* Strong understanding of the healthcare industry and regulatory environment, including in-depth knowledge of medical and specialty products.
* Demonstrated ability to effectively coordinate multiple projects simultaneously.
* Experience communicating for impact.
* Experience maximizing work practices.
* Ability to turn data into information.
* Experience performing business information analysis.
* Experience providing E. Business support.
* Ability to perform Issue identification and analysis.
* Ability to assess risk.
* Familiarity with Microsoft SharePoint.
* Familiarity with Microsoft Word.
* Familiarity with TE Microsoft Excel.
Preferred Qualifications
* Creating Accountability
* Developing and Executing Strategy
* Driving a Culture of Compliance
Education
Bachelor's degree or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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