Job Description

CHG’s business users need to exchange electronic data with internal teams, external stakeholders, and contracted vendors. The Senior EDI Analyst will provide guidance and mentorship to team members, ensuring the growth of their skills and knowledge in business processes and systems. Additionally, the role requires hands-on involvement in critical system updates, upgrades, and recovery operations to ensure continued functionality. The Senior EDI Analyst will also support the EDI Applications Manager and provide leadership to the team as delegated by the manager. This position will continue to meet with the appropriate business users to determine business needs and to gather information in order to define and develop EDI related processes, reports, and applications. The Senior EDI Analyst will work within a team of developers and analysts to plan, design, implement, and test EDI systems in support of Community Health Group’s (CHG) core Medi-Cal and Medicare insurance programs. This position will also provide technical assistance to Information Systems (IS) staff, and develop written documentation such as specifications and operational procedures.

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including DHCS, CMS, Cal MediConnect), and Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange (CAQH CORE).

Requirements

Train and Mentor new EDI team members to do the following:

• Effectively Document EDI Processes, requirements, and test plans.
• Design, develop, implement, and maintain EDI x12 transactions and processes.
• Collaborate with Software Developers or Vendors to design, purchase, or configure EDI applications.
• Configure QNXT EDI modules and establish connections with trading partners..
• Work with Clearinghouses to resolve issues.

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

• Lead continuous improvement efforts, proactively identifying opportunities for system optimizations and working with the team to implement solutions that increase efficiency, security, and scalability.
• Automate data imports and exports through scheduled tasks, SQL scripts, SSIS packages, and C# applications .
• Build and maintain database repositories to store incoming data efficiently.
• Configure and debug BizTalk orchestrations to transform data and import it into repositories.
• Configure other EDI components, including, QNXT, TIBCO, MoveIT, and SFTP servers.

Ensure CHG’s compliance with regulations and the stability of business operations by:

• Performing system upgrades and deployments after hours.
• Diagnosing and resolving system issues related to EDI processes.
• Assist with Encounter Data submissions and monitor data quality and timelines.
• Coordinate with Claims and Enrollment Departments for Encounter Data and Enrollment submission data Processing.
• Collaborate with internal departments to ensure that EDI processes and submissions comply with the latest DHCS, CMS, and CAQH CORE regulations. Assist with audits and updates to ensure continuous compliance.
• Lead compliance audits for EDI processes to ensure full adherence to HIPAA, CMS, and state/federal regulations, proactively identifying gaps and recommending solutions.
• Collaborate with leadership to develop strategies for maintaining regulatory compliance across all EDI systems, ensuring continuous adaptation to new or changing regulations.

Provide technical leadership within the team by:

• Becoming a subject matter expert on new technologies, including new file formats and data management principles.
• Lead the implementation and maintenance of a customer service ticketing system for resolving EDI-related issues.
• Maintain up-to-date EDI Companion Guides and provide support for QNXT upgrades and system maintenance. Supporting QNXT upgrades and System Maintenance activities.
• Develop and update technical documentation such as system specifications, user guides, and desktop procedures.
• Provide subject matter expertise on complex EDI architectures, leading the integration of FHIR and HL7 standards into CHG’s systems to improve data exchange and interoperability.
• Participate in ongoing professional development and staying current with the latest EDI technologies and regulatory changes.

Project Management

• Serve as the primary liaison between CHG and third-party vendors, overseeing the selection and implementation of new EDI applications and ensuring performance standards are met.
• Negotiate and manage service-level agreements (SLAs) with vendors to ensure that EDI systems are optimized, maintain compliance, and meet performance benchmarks.
• Develop and execute strategies that optimize CHG’s EDI capabilities, resulting in cost reductions, faster claims processing, and enhanced service delivery to internal teams, vendors, and business stakeholders.
• Oversee and manage the full lifecycle of complex EDI projects, including scoping, planning, execution, and delivery. Ensure that projects meet business objectives, stay within budget, and adhere to timelines.
• Implement Agile methodologies for project management to drive efficiency and improve cross-department collaboration on EDI-related initiatives

Other duties as required to meet CHG business goals.

Education:

Bachelor’s Degree in Information Systems/Computer Science/Engineering or Bachelor’s Degree in other fields with equivalent experience.

Experience/Skills:

4 Years of experience as an EDI Analyst or comparable position

2-5 years healthcare background is required. Managed care experience preferred.

Experience with EDI systems analysis and design

Expert level knowledge in SQL Server - writing high level SQL Scripts

Expert level knowledge in HIPAA rules and guidelines

Expert level knowledge of DHCS EDI requirements surrounding Program Data, Network Data, and Encounter Data.

Expert level knowledge of QNXT.

Experience with BizTalk and ability to configure Trading Partners.

Experience with EDI Mapping; experience working with multiple integrated systems; experience with developing specifications, test plans, and system documentation preferred.

Experience with MoveIT and TIBCO.

Experience with the C# programming language.

Excellent oral and written communication.

Excellent analytical, logical and organizational skills.

Strong problem-solving, analytical, and interpersonal skills, with the ability to work collaboratively across teams and mentor junior analysts.

Excellent time management; able to work on multiple projects concurrently.

Ability to adhere to security requirements and confidentiality as required by the company and HIPAA.

Knowledge of the followings specifications or transaction sets:
• X12 EDI HIPAA transaction sets: 820, 834, 274, 270/271, 276/277, 277CA, 835, 837 P/I, 999
• HL7, XML, FHIR
• DHCS pharmacy encounter data NCPDP File

Knowledge of CAQH Core Operating and ONC Rules

Certified Production Owner.

Physical Requirements:

May be required to work evenings and/or weekends.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

Job Tags

Similar Jobs