CareMedic Systems

Payer Manager -EDI

Department:   Product Management
Reports To:       Director Product Management
Status:            Permanent, Full Time
Category:        Salary, Exempt
Location:         St. Petersburg, FL 
Revision Date:  July 25, 2008

Position Summary:

The Payer Manager is responsible for managing the EDI Analyst staff, determining the work flow of the payer department, improving payer processes and assuring the appropriate edits and edit types are maintained for CareMedic’s transaction based products. In addition, the payer manager will review and approve payer requirements and will establish and maintain a process to assure review of all applicable government regulation related to payer edits and set up. The person in this role will act as liaison between the payers, the development team, client services and production control in the implementation of new payer connections and current connections.

Essential Duties and Responsibilities: 

• Develop a solid understanding of all CareMedic products
• Approve and review any changes to the guidelines and regulations governing billing of patient services to Medicaid, Medicare and all other payers
• Strong analytical and management skills
• Ability to consolidate, translate, and apply billing information collected from CMS newsletters, payer website internet research, and payer telephone.
• Manage the integrity of claim editing logic across payers, to ensure appropriateness of edits and increase consistency across payers.
• Actively communicate with management of the status of projects
• Manage the edit change control process including tracking, research and investigation, obtaining input and conducting regulatory impact analysis of the change
• Manage and establish policies and procedures for edit implementations including coordination with the programming and QA team to configure changes and test changes.
• Manage and establish payer enrollment policies and procedures.
• Advise management and other staff on the impact of pending and future anticipated potential coding, regulatory and other payer requirement.
• Manage and approve complex EDI Maps and mapping specifications, including approving the documentation of all EDI process flows.
• The ability to manage and communicate with others in a clear, understandable and professional manner on the phone, via email and in person.
• Ability to manage staff and schedule flexible work schedules.

Supervisory Responsibilities:

Qualifications:
The person successfully performing this role will exhibit the following competencies and /or meet the following minimum requirements: 

• Ability to lead and manage a team while meeting deadlines in a fast paced environment.
• Strong leadership, supervisory experience and excellent verbal and written communication skills.
• Ability to manage and juggle multiple priorities, keeping everyone on target.
• Must have solid background in ANSI X12 formats and implementation guides. Specific knowledge of 270, 271, 276, 277, 278, 820, 834, 835, 837 and HIPAA standard code sets is required.
• Experience with electronic commerce gateway software tools. Extensive knowledge of EDI systems, operations, policies and procedures.
• Familiarity with various communications applications and have working knowledge of protocols such as FTP, HTTP, TCP/IP, etc.
• Self starter with the ability to work independently with little or no supervision. Must have good common sense.
• Knowledge of multiple types of medical coding such as ICD, CPT, HCPCS and UB04 and CMS1500 claims form.
• Bachelors degree required
• 10+ years hands on technical experience; concentration in management of healthcare billing, clearinghouse operations, payer enrollment requirements and EDI transaction processing.
• Extensive Knowledge of guidelines and regulations governing billing of Medicaid, Medicare and all other payers
• Project Management experience preferred.
• Prior managed care experience helpful.

Travel
Minimal Travel Required <10%.

Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to use hands and arms, including the need to reach with arms. The employee is frequently required to sit; stand; walk; reach with hands and arms; balance; stoop; kneel and/or crouch. The employee must occasionally lift and/or move up to 20 pounds.

Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to computers, printers and copiers. The noise level in the work environment is usually moderate.