ProMedica’s health plan, Paramount Insurance, offers health insurance products across six Midwest states. Paramount is an Ohio-based health insurance company, headquartered in Toledo. The organization has more than 800 employees dedicated to serving their health plan members.

Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality Assurance (NCQA) for their HMO and Medicare Advantage products.

In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers’ compensation, as well as vocational rehabilitation, life-care planning and wellness.

As a part of ProMedica, Paramount is driven by ProMedica’s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website. http://www.paramounthealthcare.com.

REPORTING RELATIONSHIPS/SUPERVISORY RESPONSIBILITIES

This position reports directly to the Assistant Manager of Operations for Paramount Dental. This position reports indirectly to the Manager of I.T. Services for Paramount Dental may have indirect reporting to the Manager of EDI Services for Paramount Health Care/ProMedica IT Services.

POSITION SUMMARY

The EDI Specialist for Paramount Dental coordinates and executes all Electronic Data Interchange (EDI) processes for the organization to achieve strategic and operational goals through growth initiatives, regulatory compliance, and system integration. This position collaborates with the Paramount Dental leadership team and business areas to ensure timely and accurate delivery of electronic data to best serve our Patients/Members, Providers, and Employer Clients. This position may interact/collaborate with external partners including third-party vendors (clearing houses, data exchange partners, employer clients, etc.)

ACCOUNTABILITIES

• Establish, maintain, and process all net-new and existing client EDI connections and file transfers to support business needs. Identify data gaps and manage remediation for all EDI files.
  • EDI tasks/duties for this role will include but not be limited to the following processes that need to be maintained and or established:
    • Eligibility requirements (EDI 270/271)
    • Claims (EDI 837)
    • Authorizations (EDI 820)
    • Benefit enrollments (EDI 834)
    • Acknowledgments (EDI 834)
    • Payment remittances (EDI 835)
• Responsible for EDI processes and documentation that support daily business functions.
• Apply knowledge of medical, dental, and/or behavioral health claims, encounters, and enrollments/eligibility file processing.
• Apply knowledge of HIPAA transaction guides, data elements, and user requirements.
• Assist in the development/creation/documentation of data mapping for all HIPAA/proprietary transactions and participate in QA (Quality Assurance) of mapping/translations before the release of EDI file processes in production.
• Conduct research using a variety of SQL, XML, EDI, and file editing tools such as Microsoft SQL, etc.
• Assist data and report analysts in developing data validation routines, building discrepancy reports, etc. for EDI files (including but not limited to claims, enrollment files for clients, etc.).
• Acts as primary liaison between Claims/Encounter, Enrollment/Eligibility, and Customer/client production personnel.
• Implementation + Companion Guide Knowledge/Understanding/Duties:
  • Support mapping processes from a database using HIPAA Compliant Implementation Guide (IG) and Customer Companion Guide (CG) Transaction documentation and/or other proprietary formats to meet Customer/client requirements, as well as all associated documentation.
  • Companion Guides: Demonstrate and apply knowledge of state and federally mandated Companion Guide guidelines and their use. Conducts/updates/manages analyses and documents transaction requirements based on Implementation Guide, Companion Guides, and proprietary format instructions.
• Other duties as assigned.

REQUIRED QUALIFICATIONS

Education: Bachelor’s Degree in Computer Science, Management Information Systems, or other computer or business-related field.

Experience: 1-3 years of experience working with EDI technologies, processes, and logistics.

Skills:

• Excellent analytical and problem-solving skills.
• Excellent listening, communication, and interpersonal skills.
• Ability to effectively prioritize and execute tasks in a fast-paced environment.

Years of Experience: 1-3 years healthcare industry and/or quantitative work experience.

License: N/A

Certification: N/A

PREFERRED QUALIFICATIONS

Education: Master of Computer Science, Management Information Systems, or Business Administration.

Experience: Experience with EDI technologies, processes, and logistics are highly beneficial.

Skills:

• 3-5 years of knowledge/experience of health/dental insurance, healthcare industry, and understanding of EDI 834, 835, and 837 generation/maintenance/exchange.
• 5-7 years of experience with healthcare EDI technologies, processes, and logistics.

License: N/A

Certification: N/A

ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace