Analyst, EDI Claims-Remote

Putting People First in Pharmacy- Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.

We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

The EDI (electronic data interchange) Claims Analyst ensures efforts are in alignment with the Claim Adjudication Operations (CAO) team to leverage technology and process improvement for the purpose of meeting the business needs of Navitus customers, clients, members, and pharmacies by accurately administering benefits. This role is responsible for the establishment and ongoing monitoring of EDI files received from external partners for batch claim processing of subrogation and other payer claims. The EDI Claims Analyst position also requires knowledge of both the technical and operational sides of the business.

Individuals in this role will maintain a working knowledge of manual claim processing and will partner with development resources to champion the enhancement of current processing. This role will also work closely with Compliance, Finance and Government Programs teams to meet subrogation regulatory requirements. The EDI Claims Analyst will have direct authority to make sound business decisions regarding client claims EDI data and will demonstrate the ability to continually prioritize day to day workload to meet individual, departmental and organizational goals for service and performance.

This position may include after-hour and/or weekend hours depending on workload.

Is this you? Find out more below!

How do I make an impact on my team?

• Implements new EDI inbound claims files and outbound eligibility data and maintains established EDI exchanges.
• Monitors and resolves EDI claims batches to ensure accurate adjudication of benefits in the claims processing system.
• Works directly with client contacts, EDI vendors and Navitus’ Account Management team and participates as EDI claims subject matter expert in all assigned new client implementations and/or existing client change projects and related meetings and communications.
• Analyses vendors’ custom, inbound file layouts, interprets appropriate translation of data elements and prepares data mapping specifications for IT development.
• Uses self-directed, sound business judgment and expertise to identify, define and formulate root cause analysis of EDI process issues. Documents results of analysis and makes recommendations for corrective action plans and process improvements.
• Adapts to industry changes and evolving technology, maintaining an advanced level of understanding of both legacy and emerging products and systems.
• Participates in process re-design, service improvement, cost reduction and automation efforts to streamline current EDI processes.
• Contributes to the creation, peer review and ongoing maintenance of departmental training materials, work instructions and policies.
• Generates queries and reports to monitor EDI claims and identify/troubleshoot issues and fulfills special reports requested by clients, leadership and other departments on an ad hoc basis.
• Educates other roles on EDI claims process and responds to customer questions and issue resolution requests.

What our team expects from you?

• Associate degree or equivalent work experience
• Minimum of two (2) years of experience in manual claims processing and/or data file management.
• Experience with the following tools at an intermediate to advanced level preferred:
  1. Claims Processing
  2. Microsoft Office (Word, Excel, PowerPoint)
  3. Text Editing (Notepad++/UltraEdit)
  4. Request Management (Service Desk)
  5. Reporting (3D QlikView/QlikSense)
  6. FTP File Transfer/Retrieval (FileZilla)
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Hours/Location: Monday-Friday 8:00am-5:00pm, CST-Remote
• Paid Volunteer Hours
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!
• Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Nine paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program