EDI Analyst
Harvard Pilgrim Health Care - Quincy, MA

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Reporting to the Manager, eBusiness Operations, the EDI Analyst is responsible for management of Harvard Pilgrim Health Care’s most significant eBusiness (high volume claims submission or influential or “core” network) provider accounts. Responsibilities include increasing and maintaining use of electronic claims submission and claims remittance advice, and other key electronic business transactions via Harvard Pilgrim Health Care’s preferred direct channels. The EDI Analyst spends 50-75% of time in specialized responsibilities in operational and project areas including team lead role, vendor management, data analysis, project or release management functions, HIPAA transaction testing and implementation or HIPAA compliance. The EDI Analyst will need to be proficient in all transactions, including the most technically complex.

Serves as primary contact between Harvard Pilgrim Health Care and providers, vendors and billing agencies for information, status and opportunities regarding eBusiness transactions, eBusiness direct channels, and HIPAA requirements for eBusiness channels.

Manages complex provider account issues, determines if Harvard Pilgrim Health Care implementation assistance will be provided, identifies level of assessment or implementation support at appropriate cost to Harvard Pilgrim Health Care, etc.

Develops and implements provider/vendor/billing agency specific overall strategic connectivity plans to reduce paper/phone/fax transactions and increase electronic business: claims submission, remittance advice receipt, claims and eligibility inquiry and reply, and referral/authorization submission.

Monitors activities of providers/vendors/billing agencies against strategic plan and develops and implements corrective action plans as necessary. Gathers provider/vendor/billing agency competitive intelligence and feedback regarding Harvard Pilgrim Health Care direct eBusiness services to identify product improvement opportunities.

Maintains current and thorough knowledge of Harvard Pilgrim Health Care eBusiness channels and implementation requirements and status. Requires thorough and current knowledge of HIPAA, NEHEN Net, NEHEN classic, HPHConnect for providers, HealthTrio, Harvard Pilgrim Health Care healthcare transaction service, and Secure FTP software utilized by Harvard Pilgrim Health Care for direct eBusiness transactions.

Serves as Harvard Pilgrim Health Care primary business representative for NEHEN Net and NEHEN classic sales and implementation meetings with providers/vendors/billing agencies.

Prepares and delivers marketing and sales presentations regarding Harvard Pilgrim Health Care’s overall eBusiness strategy and activities. Attends provider/vendor/billing agency trade organization meetings as requested.

Performs eBusiness Specialist I registration, enrollment and authorization tasks as needed to ensure timeliness of production work or effectiveness of trading partner HIPAA transaction testing and implementation.

Provide content and assist in developing training programs for Perot Provider Service Center, Perot Provider Relations and Health Services staff to maintain and increase knowledge and skills related to provider electronic transactions and provider connectivity options. Acts as resource for colleagues within Technology Operations and Programs, Health Services; Member Services; and Perot Provider Service Center, Provider Relations and EDI Claims.

Other duties and projects as assigned.

Bachelor’s degree or equivalent work experience.

5-10 years of experience in health care industry.

At least 3 years experience in EDI operations and/or account management related work.

Ability to maintain/develop positive, mutually successful relationships with provider/vendors/billing agencies and internal department representatives.

Strong communication skills including interpersonal, verbal, written and group presentation.

Ability to work in a dynamic environment that involves priority setting and handling multiple tasks simultaneously.

Strong customer orientation and proven ability to work well independently and in a team environment.

Highly organized with strong project management skills.

Knowledge or ability to quickly learn business software applications, NEHEN, and HPHConnect for providers.

Required Skills

Required Experience

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