Director, EDI & Encounters Business Implementation

Job Summary:

The Director, EDI and Encounters Business Implementation will oversee the strategic planning, development, and execution of Electronic Data Interchange (EDI) and encounters processing initiatives within our healthcare organization. This role is essential for ensuring the successful implementation and integration of new lines of business across all products for EDI and Encounters submissions.

Essential Functions:

• Develop and implement strategies for EDI and encounters processing that align with organizational goals and regulatory requirements
• Lead cross-functional teams to assess, plan, and execute new business implementation and integration projects concerning EDI transactions, including but not limited to:
  • 837: Health Care Claim
  • 835: Health Care Claim Payment/Advice
  • 270/271: Eligibility Inquiry and Response
  • 276/277: Claims Status Inquiry and Response
  • 834: Benefit Enrollment and Maintenance
• Collaborate with IT, operations, finance, and compliance teams to enhance data exchange processes and technology solutions
• Establish and maintain relationships with external partners, payers, and vendors to facilitate seamless EDI transactions
• Monitor industry trends, best practices, and regulatory changes related to EDI and encounters to ensure compliance and operational excellence
• Provide training and support to staff on EDI processes and tools, fostering a culture of data integrity and accuracy
• Analyze performance metrics and data reporting to identify areas for improvement and drive operational efficiencies
• Prepare and present regular reports to executive leadership on the status of EDI initiatives and new business implementations
• Establish and monitor key performance indicators (KPIs) to measure project success, identify improvement areas, and provide regular progress reports to leadership
• Partner with IT to develop and implement technical strategies that ensure scalable, maintainable, and high-quality solutions
• Demonstrate the ability to lead a team through problem-solving and creative solutioning
• Lead presentations with audiences ranging from technical stakeholders to client executives
• Serve as the escalation partner for all technical project components, standards, business, and strategic objectives
• Accountable for the development and implementation of policies, procedures, and standards of EDI and encounters for new market implementations
• Lead discussions with vendors and internal stakeholders on EDI and encounters requirements needed for implementation
• Facilitate comprehensive discussions with vendors and internal stakeholders to gather, analyze, and document detailed requirements for EDI and encounter implementations
• Work collaboratively to define project scope, address technical and operational needs, and establish clear timelines for successful completion
• Manage the overall testing of the EBusiness / Encounters implementation as it relates to new market implementations, including EDI claims received from trading partners and direct submitters, claims submitted via provider web portals, paper claims received via paper vendor and pass-through Encounters files received from delegated vendors, ensuring quality of data is maintained
• Responsible for coordinating testing with internal quality assurance and vendors, develop comprehensive test plans, monitor test execution, and issue resolution
• Perform any other job duties as requested

Education and Experience:

• Bachelor's degree in business administration, healthcare administration, a related field, or equivalent years of relevant work experience is required
• Minimum of ten (10) years of experience in healthcare EDI, claims processing, or a related field, with at least five (5) years in a leadership role required
• Three (3) years of project management experience is required
• Edifecs Smart Trading Platform (ST) and Encounters Management (EM) experience is required
• Facets and/or equivalent experience of claims adjudication system is required

Competencies, Knowledge and Skills:

• Advanced skills in Microsoft Office suite
• Proven track record of successfully implementing new managed care products
• Exceptional project management acumen, familiarity with relevant tools and a proven track record of successfully implementing new managed care products
• Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, check write, mass claims adjustments, batch processing, remittance advice process, reimbursement methodology, and project management toolsets
• Demonstrated strategic acumen and ability to drive operational excellence
• Outstanding written and verbal communication skills
• Effective listening and critical thinking skills
• Extensive knowledge of healthcare data standards, including X12 transaction sets, and a strong background in project management and stakeholder engagement
• Demonstrated strong problem-solving and decision-making skills
• Ability to create and maintain effective working relationships

Licensure and Certification:

• Project Management Professional (PMP) certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Occasional travel may be required to meet business needs

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.