Engineer III - EDI

Inland Empire Health Plan•Rancho Cucamonga, CA

2d•Hybrid

About The Position

Under the direction of the Encounters & EDI Leadership Team, the Engineer III is responsible for analysis of new DHCS/CMS requirements and providing recommendations for new rules implementation, submissions tracking, remediating submission errors, responding to regulatory changes, and monitoring encounter submissions to DHCS and CMS, and acceptance compliance. The Engineer III also is responsible for BRDs creation and communication with Trading Partners. The Engineer III must be able to work independently, often working directly with business users and IT groups to understand and document requirements. The Engineer III will work cross-functionally with department leaders to deliver actionable analyses / results. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Six (6) years of relevant work experience
Bachelor's degree from an accredited institution required
In depth knowledge of Healthcare HIPAA requirements and CA State and CMS regulations and X12 formats
Expertise in SQL, SSRS. Knowledge of EDIFECS or similar tools is a plus
Extensive knowledge of Microsoft Office (Excel, Word, Visio, and Power Point) is essential
Must be able to handle multiple projects, prioritize to meet deadlines, and develop effective working relationships
Strong problem-solving capability, excellent interpersonal, and communication skills
Ability to explain complex data analyses and findings in a way that is easy to understand and appropriate to the audience. Strong attention to detail

Nice To Haves

Master's degree in Data Science, Informatics, Public Health, Epidemiology, or a related field from an accredited institution preferred
Knowledge of EDIFECS or similar tools is a plus
Working knowledge of medical terminology, knowledge of managed care, eligibility and/or pharmacy processes, and insurance terminology preferred

Responsibilities

Present findings of analyses to various staff levels. Present results in formats that are easy to understand and appropriate to the audience.
Provide recommendations for necessary changes in existing EDI processes.
Monitor and Track quality and completeness of data submitted to CMS and DHCS.
Analyze rejections and provide recommendations for remediation.
Guiding team members on topics related to encounters submissions to IEHP’s regulatory bodies, remediating submission errors.
Communicate with Trading Partners/ CMS/DHCS on needed basis
Create BRDs
Clear understanding of IEHP business operations
Responsible for managing assigned projects and effectively communicating project team to ensure project deliverables and deadlines are met.
Document and ensure assigned project / technical staff document all analysis / reporting projects following established protocols, ensuring replication of results by an independent reviewer.
Demonstrate a commitment to incorporate LEAN principles into daily work.
Establish and maintain effective working relationships with others throughout the organization.
Any other duties as required to ensure the Health Plan operations are successful.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.