Guiding you to wellness with innovative tools, equitable access, and a personal touch. Avēsis creates communities and systems of care where everyone has access to quality healthcare and services while being treated with dignity.

Founded in 1978, Avēsis is a leading administrator of supplemental insurance benefits for government and commercial plans. Rooted in the communities we serve, Avēsis prides itself in delivering innovative products and services while placing our more than 6.6 million members at the center of everything that we do.

Our chosen EDI Data Analyst will ensure accurate and timely Encounter/Rejection file processing for submission to the respective State and/or client. This individual will utilize their knowledge of overall claims processing to provide input on Encounter/Rejection opportunities for improvements and to resolve/reduce Encounter Rejection errors.

Core Competencies

• Collegiality: Building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.
• Initiative: Readiness to lead or take action to achieve goals.
• Communicative: Ability to relay issues, concepts, and ideas to others easily orally and in writing.
• Member-focused: Going above and beyond to make our members feel seen, valued and appreciated.
• Detail oriented and thorough: Managing and completing details of assignments without too much oversight.
• Flexible and responsive: Managing new demands, changes, and situations.
• Critical Thinking: Effectively troubleshoot complex issues, problem solve and multi-task.
• Integrity & responsibility: Acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.
• Collaborative: Ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Essential Functions

• Engage actively with the Encounter and Implementation teams to understand the steps of the encounter/rejection process for states/clients.
• Participate in State/Client Encounter discussions, acting as a subject matter expert and providing input on suggested process improvements.
• Accurately interpret and understand State Encounter/Rejection requirements for multiple markets.
• Develop and maintain controls over the Encounter processed data and systems.
• Oversee the auditing process and monitor exposure and potential penalty risk. Improve process as business dictates.
• Resolve escalated issues on behalf of EDI staff; work with internal staff as needed to ensure the resolution of escalated issues related to Encounters/Rejections.
• Analyze exception data and correct code errors/issues. Submit accurate and timely Encounter Acceptance Rate Reports.
• Identify trends and inefficiencies in procedures, reports, and workflow to support continuous improvement.
• Provide feedback to the manager on recommendations for additional training or coaching to foster continued staff development.
• Partner with the management team to resolve potential issues and concerns.

Minimum Qualifications

• Associate degree in Business Administration/or Healthcare related field or 5-7 years of related work experience.
• 3-5 years of prior job-related experience demonstrating strong analytical capabilities in claims/encounter processing
• 3-5 years of Strong SQL experience ( create multi-level queries, database maintenance – backup and restore, execute stored procedures, interface with other apps using SDK/API)
• Strong knowledge of database application and data query protocol (MS SQL Server, Transact-SQL).
• 3-5 years comprehensive experience claim processing/resolution
• 2-3 years experience with standard EDI file formats and protocols such as 837P, 837D, 835, 834, 277, 999.
• Excellent knowledge ADA, CPT and HCPCS procedures and codes.
• Basic knowledge of Microsoft software (Outlook, Excel, and Word).
• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.