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Director, Electronic Data Interchange and Claims Support Services

Job Category:  Management/Executive
Department:  Claims Data and Support Services
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8266

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Director, Electronic Data Interchange (EDI) is primarily responsible for transforming the way L.A. Care works with our PPGs, Plan Partners, DHS, and others in electronic data exchange. An ability and interest in continuous improvement along with a good understanding of the evolving Electronic Data Interchange (EDI) marketplace is critical. The EDI Director will also lead the team of EDI Managers and Team Leads that support the EDI end to end (input/output) processes. This includes the definition and implementation of new and improved automated processes, managing the department by establishing the daily monitoring of EDI file processing, the troubleshooting of issues impacting successful receipt or delivery of EDI files, the setup and testing of new additions to existing trading partner.  This position owns the Member Out of Pocket Accumulator process and is responsible for oversight, remediation, and enhancements of this business process.  In addition, the Director owns the Electronic Load of Delegated Authorizations (ELDA) as well as the loading of all internally created authorizations into QNXT. The Director will lead all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. 

Duties

Work collaboratively with stakeholders and other carriers on member enrollment processes, file prioritizations, deadlines, improving quality and efficiency. Communicate system and interface availability, modifications, and problems to internal and external stakeholders as needed and according to established policies and procedures. Support stakeholders and trading partners with their non-standard requests for ad hoc reports, testing analysis and other technical deliverables. 

Ownership of the End-to-End Accumulator process.  Oversight of the transmittal of files, claims, encounters, etc., with accumulator information.  Validation of the MOOP data throughout the system (intake/accumulator DB/QNXT/threshold certificates) to ensure accuracy of member out of pocket calculations.  Directs the timely remediation, as appropriate, for member reimbursement and issue tracking/resolution.

Oversight of authorization data as it flows through-out L.A. Care's various systems.  Manage the development of reports to track end to end reporting of authorizations from ELDA to QNXT; focus on timeliness, errors and timeliness to correct, volumes (understanding volumes being loaded into the system).

Directs cross-functional work, as needed,  to improve authorization timeliness and success rates for loading into the system as well as increasing the number of auths (ELDA & CCA/Syntranet) that successfully get loaded into QNXT. Oversight of development, implementation, and ongoing monitoring and enhancement of roadmap to eliminate the need for examiners to search for authorizations manually.

Ensures adherence to End-to-End control plan and monitoring of electronic data to ensure it is moving through the system as designed.

Analyze and develop specifications for EDI enhancements, automation and improvements. Use access to data and personal observation to identify potential process improvement opportunities. Implement process improvements to enhance the efficiency of the EDI processes. Perform routine and ad hoc analysis of various facets of EDI processing including but not limited to system performance, data mapping, and file transaction volume. Prepare and maintain documentation that defines operational procedures, describes client requirements, and shares relevant analysis outcomes with internal and external stakeholders.

Manage the EDI team including development of performance metrics that the team will be measured against. Oversee the production support of existing EDI trading partners. Manage the production environment and proactively prioritize, communicate, and resolve any EDI process or system issues. Manage and assist in resolving EDI issues called in to the Help Desk. 

Directs staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Provide ongoing training and mentorship of team members. Complete job-related training courses and/or seminars, as may be required for the job and/or assigned by the Senior Director. 

Work with other Directors and Managers to ensure smooth interaction and processes for stakeholders

Perform other duties as assigned.

Education Required

Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Master's Degree

Experience

Required:
At least 7 years responsible of experience in a technical production or applications support role in a health plan or related environment with 5 years of supervisory/management experience. 

Experience negotiating with external partners.

Experience with writing functional design documents, troubleshooting EDI failures, and with unit testing methods.

Working knowledge of relational databases and maintenance.

Working knowledge of health plan eligibility and enrollment processes.

Preferred:  
Prefer candidates with Use Case or Process Flow diagrams development experience.

Prefer candidates with XML format experience.

Experience working with member out of pocket accumulator data.

Commercial health plan experience.
 

 

Skills

Required:
Very strong I.T. and EDI background.

Exposure and general understanding of Healthcare claims processing and carrier protocol as it pertains to claims filing/processing.

Superior customer service skills, preferably in a technical implementation capacity.

Strong analytical skills, an attention to detail, strong oral and written communication skills, and the ability to self-start and self-motivate.

Proficient in SQL, MS Access, MS Excel, MS Word and Outlook.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Claims, Insurance

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