About Pediatrica Health Group Inc.

Every day is a good day to prepare for a healthy tomorrow. Providing children and their families with equitable access to quality pediatric care to build a foundation for a lifetime of optimal health and wellness is what drives our team to deliver its best every day. It’s our purpose.

Offering focused care from tots to teens, our pediatric primary care providers and teams partner with families to foster good health and strong, thriving communities. Second-to-none medical staff and top-tier administrative professionals keep our practices running smoothly and make each patient experience the best we can offer.

Working in partnership with patients, families, and communities who put their trust in us for their care, we hold ourselves accountable to ensure equitable access to care, advocate to create impactful change, and continually learn and progress to create better outcomes and brighter futures. Together, we’re paving the way for kids to develop into healthy young adults. Rooted in these values, we continue to grow and serve. Are you ready to join us?

POSITION SUMMARY:

The EDI Business Analyst Specialist designs, implements, supports, and validates practice and provider constructs within the clearinghouse. This position includes monitoring of data feeds and related loads to ensure systemic risks are identified and corrected across all Pediatrica Health Group practices.

Success in this position includes assisting in the growth and maintenance of our clearinghouse solutions by researching industry changes and data sets, analyzing data trends, identifying areas of opportunity, and aiding in the implementation of these enhancements. Ideal candidates have a naturally analytical way of thinking, can quantitatively and qualitatively analyze information, are process-oriented, and enjoy research and team collaboration.

ESSENTIAL FUNCTIONS

Clearinghouse & EDI Operations

• Design, implement, support, and validate practice and provider constructs within the clearinghouse.
• Monitor data feeds and related loads; identify and correct systemic risks before they impact claims or revenue. Develop and maintain a professional relationship with the clearinghouse partner and their staff.
• Research industry changes and data sets, analyze data trends, and support the implementation of clearinghouse enhancements.

 Process Analysis & Optimization

• Work closely with RCM leadership and staff to evaluate business processes, anticipate requirements, identify improvement opportunities, and develop and implement optimization strategies.
• Stay current on the latest medical billing processes and guidelines to identify claim-editing, fee-schedule, and systemic changes for implementation.
• Perform gap and issue analyses, root-cause assessments, and resolution planning.
• Adapt policy-related documentation to requirements and conduct refinement analysis to ensure solutions meet business needs.

 Collaboration & Communication

• Conduct meetings and presentations to gather critical information, share ideas and findings, and effectively communicate insights and plans to cross-functional team members, with a focus on IT relationships.
• Create detailed reports and present data to stakeholders; influence stakeholders and work closely with them to determine acceptable solutions.

 Testing, Projects & Documentation

• Perform system integration testing and user acceptance testing (UAT).
• Assist with project management, including developing project plans and monitoring performance to ensure initiatives are prioritized based on business needs and requirements and that deliverables are on track for timely completion.
• Update, implement, and maintain department procedures and documentation.

 KNOWLEDGE, SKILLS & ABILITIES

• Deep knowledge and understanding of professional claims processing and adjudication in the healthcare and health insurance industry.
• Well-versed in revenue cycle management compliance, claim edits, rejections, and loop and segment errors.
• Demonstrated knowledge of EDI document types, including 837, 277CA, 834, 835, TA1, 999, 820, and NCPDP D.0.
• Superior analytical and conceptual thinking skills; strong technical skills.
• Strong planning, organizational, and time-management skills.
• Excellent verbal and written communication and documentation skills.
• Advanced proficiency with Microsoft applications, including Word, Excel, and Outlook.
• Familiarity with relational databases (SQL) preferred.
• Maintains strict confidentiality and full HIPAA compliance.
• Collaborative, dependable, and adaptable to changing priorities and workflows.

 EDUCATION & EXPERIENCE

• Bachelor’s degree in health information management, business, information systems, or a related field, or an equivalent combination of education and experience, preferred.
• 5+ years of experience as a business analyst or EDI analyst in a healthcare practice setting, preferred.
• Experience with eClinicalWorks or a comparable practice management/EHR system, preferred.
• Experience with pediatric or multi-specialty, multi-entity billing environments is a plus.

SUPERVISORY RESPONSIBILITIES

No direct supervisory responsibilities.

WORKING CONDITIONS

General office working conditions.

PHYSICAL DEMANDS

The physical demands described here are representative of those an associate must meet to perform the essential functions of this job successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing this job, the associate may need to stand, walk, sit, handle objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch, or crawl; and talk or hear. The associate must occasionally lift or move up to fifteen pounds. Required vision abilities include close, distance, and peripheral vision; depth perception; and the ability to adjust focus. Occasional travel may be required. Manual dexterity is required to operate desktop computers or laptops. The employee may be exposed to varying weather conditions.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an associate must meet to perform the essential functions of the job successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

TRAVEL

Minimal travel may be required for training, meetings with the clearinghouse partner, or visits to PHG practice locations.

SAFETY HAZARDS OF THE JOB

Minimal Hazards