Manager of EDI, Eligibility, and Capitation

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Job description

Position Overview:

The Manager of EDI, Eligibility, and Capitation will be responsible for the day-to-day management of electronic data interchange (EDI) systems, eligibility verification, and capitation processes within the MSO. This position supports accurate and timely data exchange between the MSO, payors, and provider networks, ensuring proper handling of member eligibility, claims, and capitation payments. The Manager will oversee a team of specialists, troubleshooting issues and collaborating with internal and external partners to ensure efficient operations. This role is crucial to maintaining compliance with full-risk Medicare Advantage value-based contracts and enhancing the MSO's data management capabilities.

Key Responsibilities:

1. EDI Management

" Oversee the daily operations of EDI systems, ensuring the accurate transmission of claims, capitation, eligibility verification, and enrollment data (837, 834, 835, 270/271 transactions).

" Ensure seamless integration between EDI systems and other internal/external systems such as practice management, claims processing, and electronic health records (EHR).

" Identify and resolve EDI errors and transaction discrepancies by coordinating with IT teams, payors, and providers.

" Support continuous improvements in EDI workflows to enhance data exchange efficiency and accuracy.

2. Eligibility Management

" Manage the daily processes for eligibility verification, ensuring accurate and timely verification of member eligibility across the MSO's provider network.

" Ensure eligibility data is loaded and verified correctly from payors into the MSO's systems, maintaining data integrity.

" Troubleshoot and resolve eligibility discrepancies with providers and payors to ensure smooth operations and prevent interruptions in member services.

" Support efforts to automate eligibility verification and reduce administrative burden.

3. Capitation Management

" Oversee the calculation and processing of capitation payments, ensuring accuracy in provider compensation based on member attribution and risk scores.

" Monitor capitation agreements to ensure alignment with full-risk Medicare Advantage contracts, ensuring timely payment reconciliation.

" Work with the finance team to investigate and resolve discrepancies in capitation payments, ensuring providers are compensated accurately.

" Assist in generating capitation reports to provide insights into trends and potential issues.

4. Compliance and Reporting

" Ensure all EDI, eligibility, and capitation processes comply with relevant regulations, including HIPAA and CMS guidelines for Medicare Advantage.

" Support the preparation of reports on EDI, eligibility, and capitation operations, providing insights into performance, areas for improvement, and compliance adherence.

" Stay informed of changes in regulatory requirements affecting EDI, eligibility, and capitation processes, implementing adjustments as needed.

5. Cross-Functional Collaboration

" Collaborate with Operations, IT, Finance, and Provider Network teams to ensure data integrity and streamline EDI, eligibility, and capitation processes.

" Serve as a liaison between the MSO, payors, and providers to resolve operational issues related to data exchange, member eligibility, and provider payments.

" Coordinate with external partners to optimize data transmission protocols and address issues in data reconciliation.

6. Team Leadership and Development

" Supervise a team of EDI, eligibility, and capitation specialists, providing guidance, training, and performance management.

" Foster a culture of continuous improvement and innovation, encouraging team members to develop solutions for operational efficiency and accuracy.

" Ensure appropriate staffing levels and provide ongoing training to keep the team current with industry trends and regulatory requirements.

7. System Improvement and Innovation

" Identify opportunities to improve the efficiency and accuracy of EDI, eligibility, and capitation systems through automation and system enhancements.

" Work with IT and other stakeholders to implement technology solutions that improve data integration and reporting capabilities.

" Manage relationships with third-party vendors to ensure SLAs are met and systems function optimally.

Qualifications:

Education: Bachelor's degree in Information Technology, Healthcare Administration, Business, or a related field required.

Experience:

" Minimum of 5 years of experience in EDI, eligibility, or capitation management within healthcare.

" Strong experience with healthcare EDI transactions, eligibility verification, and capitation processes, particularly in a Medicare Advantage environment.

" Proven ability to troubleshoot and resolve data discrepancies and operational issues in healthcare systems.

" Leadership experience with supervising teams and managing day-to-day operational workflows.

Technical Skills:

" Familiarity with EDI systems, data exchange tools, and healthcare management platforms (e.g., clearinghouses, payor systems, and EHRs).

" Proficiency in SQL, XML, and other data formats commonly used in electronic data exchange.

" Experience with claims processing and eligibility systems, with knowledge of industry standards (HIPAA, ASC X12).

Leadership and Management:

" Strong problem-solving skills with the ability to lead a team and handle complex operational issues.

" Excellent communication and interpersonal skills for effective collaboration with internal teams, providers, and payors.

" Ability to manage multiple projects, prioritize tasks, and maintain focus on key objectives.

Preferred Qualifications:

" Experience in a managed service organization (MSO), Independent Practice Association (IPA), or with Medicare Advantage full-risk contracts.

" Familiarity with value-based care models and risk adjustment practices.

Work Environment:

" Office-based with the possibility of remote work flexibility.

" Occasional travel to provider sites or industry conferences may be required.

Compensation:

" $(phone number removed) -(phone number removed) per Year

" Comprehensive benefits package including health, dental, vision, 401(k), and paid time off.

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