Angel and Genie
Website:
angelandgenie.com
Job details:
Position Overview: We are looking for a US Healthcare Data Integration SME to support our Payment Integrity client onboarding and operations in the US Healthcare domain. The role involves comprehensive understanding of EDI, Healthcare Claim Form (Professional - 1500), (Facility - 1450), EDI maps for ANSI X12 transaction sets to claims model, Client claims data mapping, Data specs management, Data transformation, Data integration support, Data integrity validating, Data classification and Managing healthcare data from multiple sources to ensure accurate claims analysis, audit processes, and payment accuracy and support client onboarding.
Specialty Expertise
:Candidates must have proficiency in the following areas
- :Understanding of Revenue Cycle Management (RCM), US healthcare Claims & coding and billing
- .Healthcare Claim Form (Professional - 1500), (Facility - 1450) and EDI maps for ANSI X12 transaction sets
- .Medical Codes: CPT/HCPCS, ICD, DRG, Modifiers etc
- .Provider Data: NPI, Taxonomy Codes across all providers
- .Value sets: Standard value set in US healthcare
- .Data Integrity Validation
- .Data classification Metholodologies
- .Preferable, Clinical Data Exchange – Understanding expertise in healthcare data exchange standards (HL7, FHIR,) and clinical terminologies (SNOMED, LOINC)
.
Key Responsibilitie
- s:EDI and Interoperability Leadership: Serve as the Subject Matter Expert (SME) for Electronic Data Interchange (EDI) and healthcare interoperability. Lead the full Software Development/Implementation/Onboarding Lifecycle (SDLC) for cross-functional projects, including requirements gathering, design, testing, implementation, and post-production suppor
- t.HIPAA X12 Specialization: Specialize in HIPAA-compliant X12 transactions, with a strong focus on the 837 (Healthcare Claim File), to support payment integrity operations, data workflows, and payer-provider or payer-payer data mapping and integratio
- n.Data Specification Management: Design, develop, and maintain robust data claims model/Data Specification for healthcare claims and payment integrity systems for proof of concepts and Go-liv
- e.Data Sourcing and Transformation: Integrate data from multiple sources, including claims systems, payer platforms, and external healthcare datasets. Perform essential data mapping, transformation, and validation to ensure data accuracy and consistenc
- y.Collaboration and Alignment: Partner closely with technical teams, business analysts, and client teams to ensure regulatory compliance, seamless system integration, and process automation. Work with Payment Integrity, Analytics, and Technology teams to support audit and automation initiative
- s.Operational Excellence & Compliance: Monitor ETL processes and troubleshoot integration issues. Ensure strict compliance with HIPAA and data security standards when handling sensitive healthcare data. Act as the primary Data Integration liaison between Client and internal teams, driving timely resolution, system compliance, and stakeholder alignmen
t.
Data Quality & Improveme
- nt:Timely Delivery: Ensure the timely and accurate processing of electronic and batch data fil
- es.Quality Improvement: Investigate and resolve errors and transaction failures, significantly improving data integrity and reducing exception rat
- es.Data Quality Checks: Support data quality checks and reconciliation to identify discrepancies in claims and payment da
- ta.Data Deficiency Impact Analysis: Collaborate with Business teams to unpackage impacted ru
- lesData Integrity Library: Create, update and maintain Data integrity library for daily data validation che
- cksDocumentations: Document data flows, mappings, and integration processes for each cli
- entOperational Efficiency: Contribute to operational efficiency through comprehensive documentation, root cause analysis, and continuous improvement initiativ
es.
Team Development & Mentors
- hip:Trained and mentored junior analysts, supporting team professional development and enhancing performa
- nce.Developed onboarding guides and mentoring programs to support team expansion and knowledge retent
- ion.Co-develop automated tools with IT to correct transaction errors in real-time, eliminating multi-week del
- ays.Collaborated with developers and cross-functional teams to enhance workflow efficiency and optimize system integrat
ion.
Client Communication: Data Integr
- ationCommunicate effectively with clients to address and resolve data-related queries independe
- ntly.Analyze and interpret client-reported data issues and provide appropriate solut
- ions.Assist clients in ensuring smooth and accurate data integration proce
- sses.Proactively coordinate with clients to clarify requirements and maintain efficient data workf
lows.
Require
- ments:Strong understanding of US Healthcare data and claims processing work
- flows.Experience working with healthcare claims datasets and payer sy
- stems.ANSI X12 transaction
- sets.Claims Model mapping (EDI to Claims M
- odel).Understanding of medical coding systems including CPT, HCPCS, ICD, and modi
- fiers.Familiarity with dataset policies and rules such as Medicare and Medicaid guidelines, prefe
- rable.Familiarity of standard healthcare value set, schem
- a etc.Experience in data mapping, transformation logic, and integration document
- ation.Ability to analyze data requirements and translate them into data or business
- rules.Strong attention to data accuracy, consistency, and valid
- ation.Ability to collaborate effectively with cross-functional teams in a fast-paced enviro
- nment.Strong analytical and problem-solving s
kills.Qualifica
tions:Education & Certification (one of the following requ
- ired):Bachelor’s or Master’s Degree in Computer Science, Data Science, Information Systems, or related
- fieldMedical or Life Sciences background (MBBS, BDS, BPT, BAMS, Nursing, Pharmacy, Life Sci
ences)Certification Require
- ments:Pref
- erableFHIR/HL7, EDI Certifi
- cationCertified Health Data Analyst
(CHDA)Exper
- ience:Experience in US Healthcare Data Integration (SME), US Healthcare Data Analysis with deep understanding of Claims model, EDI 837, X12, US healthcare Codesets and dat
asets.Key S
- kills:Data Integration & Data Ma
- pping.Healthcare Claims Data Ana
- lysis.Payment Integrity and Claims Adjudication Domain Know
- ledge.Knowledge of code sets: CPT, HCPCS, ICD, DRG, PCS, Modi
- fiers.Understanding of Healthcare Claim Form (Professional - 1500), (Facility - 1450) and EDI maps for ANSI X12 transaction
- sets.Strong proficiency in SQL, Python (Preferable), Microsoft Excel and data analysis
- tools.Strong analytical, critical thinking, and problem-solving s
- kills.Excellent written and verbal communication s
kills.
Work Location: Jayanagar - Ban
galore.
Work Mode: Work from
Office.
B
- enefits: Best-in-class comp
- ensation.Health insurance fo
- r Family.Personal Accident I
- nsurance.Friendly and Flexible Leav
- e Policy.Certification and Course Reimb
- ursement.Medical Coding CEUs and Membership
- Renewals.Health
- checkup.And m
any more!
Click on Apply to know more.