Full-time (Remote in California / Hybrid)
At least 2 years of experience with Healthcare EDI, including 834, 835, and 837 files.
At least 2 years of current experience with SQL, SSIS, SSRS, XML, and XSLT a plus
Bachelors Degree or combination of education and experience
445 Grant Avenue, San Francisco, CA 94108
IT Analyst will perform analysis on clinical data and related systems and business applications to upkeep overall informatics of the company. Collaborate with assigned application users to understand document operational workflows and technology related challenges. Apply conceptual knowledge, analytical methods and problem solving skills to identify innovative information technology solutions. Analyze application and business data to identify trends/areas for improvement and propose appropriate recommendations. Responsible for data accuracy and optimal system performance to serve the needs of the organization.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Utilize Microsoft Access, SQL, Crystal Reports and other tools to mine database(s) for analytic data to produce information to support other department users.
- Use systems and data modeling tools to anticipate and proactively identify solutions to operational issues
- Document analytical approaches and methodology applied.
- Applies knowledge / expertise to complex problems
- Accepts and performs other duties as assigned.
- Conducting medical cost and revenue analyses using medical and pharmacy claims and other data sources
- Analysis of medical and pharmacy claims in the appropriate assignment of healthcare codes including but not limited to CPT, HCPC, LOINC, ICD-10, MS-DRG, APR-DRG.
- Analysis and interpretation of Risk Adjustment scores and using the HCC methods for both commercial and Medicare models.
- Develop reports and conduct quantitative analysis to understand the trend or issues and to identify the opportunity to improve the quality of care and to manage cost and utilization.
- Skilled in compiling large amounts of data into innovative presentations of information that are clear concise and actionable.
- Ensure the quality of deliverables in terms of the technical design, implementation, testing and adherence to technical compliance standards.
- Develop inpatient and when applicable outpatient Episodes of Care for focused “service lines” such as gastroenterology, hematology/oncology, circulatory and other conditions.
- Develop business rules and apply to a strategic plans to recapture health plan costs from high cost providers to quality lower-cost providers.
- Create presentations used by the Medical Management Department, Medical Directors, CEO, CFO and internal and external customers.
- Create and manage all required reporting and analysis that contribute to the overall management and success of the health plan.
EDI (Data Reporting):
- Manage daily operations to ensure timely and accurate exchange of Electronic Data Interchange (EDI) transactions.
- Provide analytical support for the implementation and maintenance of EDI transactions.
- Ensure complete documentation of EDI maps and business edits.
- Conduct EDI analysis, maintain documentation and reports for audit purposes.
- Configuration and maintenance of inbound/outbound EDI files in Core system and Data warehouse.
- Manage the execution of user acceptance testing for Healthcare EDI Transactions (ANSI X12N 835, 837, 834,999, 277).
- Design, implement, and monitor mission critical batch jobs and interfaces.
- Maintain optimum overall systems performance levels.
- Acts as supporting liaison between the application team and the user community, responsible for facilitating communications, coordinating system enhancements, and providing production support.
- Works with user community to define business requirements in sufficient detail that systems configuration, development/enhancement, and/or operations activities can be pursued.
- Works with user community to define business use cases in sufficient detail that subsequent quality assurance efforts can guarantee system changes/enhancements satisfy the business requirements.
- Works with other staff to educate/train members of the user community in proper and effective use of the application system.
- Provides implementation support for software components of moderate to high complexity.
- Provides production support for software components of moderate to high complexity.
- Identify failing processes, assess general EDI Managing scope, and system-wide deliverables for clients.
- Hardware and software requirements planning and sizing.
- Performance Tuning and Documentation.
- Bachelor’s Degree in Healthcare, Informatics, Computer Science, Information Systems or related field
- 4+ years of proven analysis experience highly preferred, or 2+ years of proven analysis experience in a healthcare/managed care environment.
- Knowledge of medical terminology, CPT, HCPC, and ICD 10 codes.
- Clinical code knowledge related to claims/utilization is highly preferred
- Experience implementing EDI concepts, practices, and procedures with extensive experience in 834,835,837 EDI Format and processing.
- Expertise in Other HIPAA/EDI X12 4010/5010 healthcare-related file formats including 820, 834, 835, 270, 271, 276, 277, 278, and 999 is preferred.
- Experience working with FTP Servers, and Transfer Protocols
- Extensive knowledge of the system development, life cycle, system, and application program, & development technology alternatives.
- Proficiency with MS Excel, BI Products, Access, SQL (queries), Server Reporting Services and database administrative support is highly preferred
- Proficiency with Crystal Reports or other report writer or visualization software is highly preferred
- Proficiency with C#, Java, or Python programming and design highly preferred
- Proficiency with SSIS, SSRS, JSON, XML, and XSLT is highly preferred
- Experience with managed care contract terms/analysis would be a plus
- Experience in a Medicare Advantage environment would be a plus
- Experience in Covered California or other similar exchange environments
- Superior analytical skills required
- Excellent technical, interpersonal, written and oral communication skills required
- Ability to work on multiple projects concurrently.
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day
In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in the start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.