The Corporate EDI Specialist is responsible for implementing techniques to reduce the financial impact and increase acceptance rate of state electronic reporting.

This role provides high-level EDI support to the local claim teams, focused on proactive claim management approaches to ensure compliance in accordance with the jurisdictional requirements.

Review EDI Report daily to determine the rejection cause and collaborate with the adjuster to facilitate corrective action for timely resubmission;

deliver feedback and coaching opportunities to the appropriate parties if trends are identified.

• Review daily strategic proactive measurement reports; distribute to adjuster and supervisor and maintain appropriate follow up activities to ensure timely claim actions and EDI transactions.
• Design and implement scorecards to evaluate the trends that are driving EDI fines and penalties; calibrate scorecards on a monthly and quarterly basis.
• Provide root cause analysis and consequence assessment to TPA Claims Compliance Manager and Regional leadership monthly and quarterly;

recommend a systemic approach to improve results within the span of control at the desk level.

• Coordinate quarterly conference calls with the claim teams to provide a high-level overview of the EDI results, along with strategies to improve compliance in the following quarter.
• Review monthly Acceptance Rate score from the state; investigate non-compliance causes and establish action plans to achieve 90% goal.
• Attend all meetings and conference calls with the state as scheduled.
• Provide strategic and technical training to new employees, and ongoing training at least quarterly to legacy employees;

maintain detailed attendance records of all training sessions; including individual coaching and feedback discussions.

• Create quarterly newsletters and design workflow guides and job aides as necessary; communicate updates to all stakeholders.
• Collaborate with EDI Claims Operations as necessary.
• Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.
• Complete additional special projects, compliance initiatives and job duties as assigned.
• Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Requirements

• Extensive knowledge of Workers' Compensation regulations, applicable laws and EDI reporting requirement; maintain appropriate jurisdictional licenses
• Advanced skills in applying sound judgement to data analysis; ability to problem solve, establish goals and implement action plans
• Excellent interpersonal skills and ability to effectively communicate to all levels within the company
• Established understanding of coaching, mentoring and training strategies
• Demonstrated computer proficiency in MS Office Product Suite, i.e. Word, Excel, PowerPoint
• Ability to travel for business purposes, approximately less than 15%

Last updated : 2024-04-27