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**Job Type:** Regular

**Time Type:** Full time

**Work Shift:** Day (United States of America)

**FLSA Status:** Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Reporting to the Director of Revenue Cycle Operations, this position is responsible for planning, coordinating and managing HIPAA EDI activities including Claims, Remittance, as well as Provider Enrollment processing for Harvard Medical Faculty Physician’s (HMFP) professional services. It is responsible for overseeing the planning and implementation of HIPAA EDI projects, working with BILH IT team and third-party vendors for EDI including analysis, design, mapping, testing, training. The Manager of EDI Claims, Remittance and Enrollment is responsible for ensuring adherence to and communicating claim requirements for HMFP contracted payers, keeping current on Federal, State, and other Third-Party rules and regulations. This position manages defined projects for HMFP Revenue Cycle, supports enterprise-wide projects and strategic initiatives, working with the Director, Revenue Cycle Optimization by investigating and developing solutions to address improvements relative to systems redesign to mitigate any compliance risk.

Job Description:

**Duties and Primary Responsibilities** :

+ Define and document HMFP’s EDI Processes

+ Design, develop, implement, and maintain EDI x12 transactions and processes.

+ Work with HMFP’s Claims clearinghouse to complete payer enrollment for electronic claims submission.

+ Lead EDI Strategic Initiatives working with HMFP’s Clearinghouse, BILH Epic IT and HMFP’s financial institution to design and configure EDI applications.

+ Develop and Maintain EDI processes to import, transform, and export data to support business objectives.

+ Implementation and testing of regulatory requirements affecting claims processing and cash posting including adherence with the most current version of following X12 HIPAA mandated transactions.

+ Oversee day-to-day production of professional claims files and transmissions, complete daily balancing, and verification. Ensure that files are being processed correctly and as scheduled, triage and ensure resolution of specific issues that may arise and facilitate communication with payors when needed.

+ Review, test and build of system upgrades or changes that effect claims processing and cash posting.

+ Lead continuous improvement efforts, proactively identifying opportunities for system optimizations by defining requirements working with the staff to implement solutions that increase operational efficiency, improve security and advance scalability.

+ Work with BILH Epic IT team to automate data imports and experts through scheduled tasks.

+ Ensure group and provider enrollment for HMFP and APHMFP provider completed.

+ Develop testing plan and scenarios for EDI processes.

+ Determine capabilities required to maintain database repositories to store incoming data.

+ Ensure HMFP’s compliance with regulations and stability of business operations by

+ Performing system upgrades

+ Diagnosing and resolving system issues related to EDI processes.

+ Assist with encounter data submissions and monitor data quality and timeliness.

+ Coordinate with HMFP departments, third-party vendors for encounter data and enrollment submission.

+ Collaborate with internal depts to ensure that EDI processes and submissions comply with latest healthcare regulations, assist with audits as assigned. Lead compliance audits for Electronic Data Interchange (EDI) processes and submissions to ensure full adherence to HIPAA, CMS, and state/federal regulations, proactively identifying gaps and proposed solutions to mitigate risk. Collaborate with leadership to develop strategies for maintaining regulatory compliance across all EDI systems, ensuring continuous adaptation to new or changing regulations.

+ Provide technical expertise related to EDI processes for HMFP Revenue Cycle by

+ Serve as subject matter expert keeping current on EDI Companion guides and providing guidance for system upgrades and system maintenance activities.

+ Develop and update any technical documentation, including but not limited to system specifications, desktop procedures.

+ Participate in ongoing professional development relative to latest EDI technologies healthcare regulatory changes, complex EDI architectures, to improve data exchange and interoperability.

+ Project Management of EDI-related initiatives

+ Primary liaison between HMFP, third party vendors and Epic overseeing the selection and implementation of new EDI applications to ensure performance standards are met.

+ Oversee and manage full lifecycle of complex EDI projects, including scoping, planning, execution, and delivery. Ensure project meet HMFP objectives, budget, and timelines.

+ Develop and execute strategies to improve efficiencies

+ Utilize Agile methodologies for project management to drive efficiency, cross functional collaboration on EDI projects

+ Ad hoc projects as assigned.

Required Qualifications:

+ Bachelor’s degree in business, healthcare administration or related field.

+ Five (5) years of experience in Revenue Cycle or hospital/clinic operations in a large complex system may be considered in lieu of the degree.

+ Working knowledge of Healthcare, Medical Terminology, Common Procedural Terminology (CPT), Health Care Procedural Coding System (HCPCS) coding and International Classification of Diseases (ICD-10).

+ Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications.

Preferred Qualifications:

+ Prior experience working with the Epic system.

+ Project management experience

+ Knowledge of regulatory requirements, healthcare /payer.

Competencies:

**Decision Making:** Ability to implement processes based on informed decisions that are guided by general instructions and practices requiring some interpretation. May identify and mitigation operational risk, make recommendations for solving problems of moderate complexity and importance.to delivery high quality operations results. Ability to make good judgments in demanding situations. **Problem Solving:** Ability to synthesize multiple sources of data and identify opportunities in support of HMFP’s objections. Strategic Thinking and analytical skills. Ability to react to frequent changes in duties and volume of work.

**Independence of Action:** Ability to logically organize work. follow precedents and procedures. Able to multi-task to execute multiple complex initiatives with an eye on the strategic as well as the operating level. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Supervisor/manager monitors work progress.

**Written Communications:** Ability to communicate clearly and effectively in written English with internal and external customers.

**Oral Communications:** Excellent communication and storytelling skills including experience with data visualization tools and presenting to executive leadership.

**Knowledge:** Ability to demonstrate full working knowledge of standard concepts, practices, procedures, and policies with the ability to use them in varied situations.

**Teamwork:** Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members. Builds relationships and partners with Departments, Key Stakeholders to provide guidance and support on thinking through strategic issues data driven.

**Customer Service:** Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.

Social/Environmental Requirements:

Work requires close attention to task for work to be accurately completed. Intermittent breaks during the workday do not compromise the work. Work routine is consistent, but employee needs to be able to use judgment to respond to events several times a week. No substantial exposure to adverse environmental conditions

**Health Care Status:** NHCW: No patient contact. - _Health Care Worker Status may vary by department_

Sensory Requirements:

Close work (paperwork, visual examination), Monitor Use, Visual clarity <3 feet, Conversation, Telephone.

Physical Requirements:

Sedentary work: Exerting up to ten pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally.

This job requires frequent sitting, Keyboard use.

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As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity** **Employer/Veterans/Disabled