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Enrollment EDI Analyst
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As a regional, provider-owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is a part of Summa Health, an integrated healthcare delivery system that includes Summa Health System hospitals, its community-based health centers, dedicated clinicians and SummaCare. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Develops, implements processes and monitors all EDI transactions as it pertains to membership/enrollments.
Formal Education Required:
a. Associates Degree or may substitute with 2 years of like experience.
Experience & Training Required :
a. 3+ years performing same or similar responsibilities. Relevant experience includes: eligibility, enrollment, premium billing, and/or reconciliation responsibilities in a managed care environment, and/or working knowledge of electronic enrollment transactions and 834 files.
Essential Functions:
1) Sets up or modifies Trading Partner Rules for new and existing clients.
2) Develops mapping specifications for EDI enrollment, and provides technical support and business analysis during and after implementation of 834 EDI applications.
3) Performs end-user acceptance testing on all inbound and outbound files as them pertain to membership.
4) Processes new EDI enrollments/changes for new and existing clients.
5) Investigates transactions rejected by CMS, FFM and other third party vendors, and takes appropriate action in accordance with defined guidelines.
6) Monitors electronic enrollment transactions in order to identify any issues with load/processing and collaborates with programming and/or clients as needed.
7) Responds to EDI inquiries and issues from external and internal organizations including trading partners, the state and CMS regarding enrollment transactions.
8) Collaborates with management in identifying, defining, and documenting process improvement options and alternatives, as directed by business needs.
9) Promotes and leads process improvement activities and training of department staff and peers.
10) Creates and maintains policies and procedures related to EDI enrollment transactions.
11) Performs all job functions with integrity. Provides timely internal and external customer service in a cooperative, professional, and respectful manner.
Other Skills, Competencies and Qualifications:
a. Ability to communicate instructional and operational information verbally and in written form that may include correspondence, reports, instructional materials, system designs; ability to provide instruction and guidance required to supervise day-to-day departmental operations; ability to interface with internal staff, mid-upper management professionals and general public.
b. Collecting, analyzing data from diverse sources; making recommendations and/or conclusions based on analyses; developing financial, data processing technical reports, procedures, systems that usually affect one department.
c. Demonstrate high degree of organization and attention to detail.
d. Demonstrate excellent technical skills with the desire and ability to learn new software programs and systems.
e. Demonstrate initiative and ability to work autonomously in a self-directed manner, and transition easily between working alone and working with groups.
f. Operate standard office machines.
g. Organize and manage time to accurately complete tasks within designated time frames in a fast- paced environment.
h. Maintain current knowledge of and comply with regulatory and company policies & procedures.
i. Maintain confidentiality of patient and business information.
j. Flexible: ability to adjust wok hours to meet business demands.
k. Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity.
Level of Physical Demands:
a. Sit for prolonged periods of time.
b. Bend, stoop, and stretch.
c. Manual dexterity to operate computer, phone, and standard office machines.
Equal Opportunity Employer/Veterans/Disabled
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.
- Basic Life and Accidental Death & Dismemberment (AD&D)
- Supplemental Life and AD&D
- Dependent Life Insurance
- Short-Term and Long-Term Disability
- Accident Insurance, Hospital Indemnity, and Critical Illness
- Retirement Savings Plan
- Flexible Spending Accounts – Healthcare and Dependent Care
- Employee Assistance Program (EAP)
- Identity Theft Protection
- Pet Insurance
- Education Assistance
- Daily Pay
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