Payer Operations & Intelligence Specialist

Division/Department: RCS, Payer Operations & Intelligence

Location: 7500 Old Oak Blvd. Middleburg heights, OH 44130

Schedule: 3 days onsite/2 remote per week following initial 3 month onsite period

Salary Range: $45k-$60k

Purpose:
The Payer Operations & Intelligence Specialist role is integral to ensure all payer electronic data interchange (EDI) transactions, corporate edits and tools are appropriately maximized across the Revenue Cycle Services (RCS) division. The role is part of a tactical team that maintains a strong knowledge of the Company’s complete claim, remittance, eligibility, and claim status capabilities, ensuring each is effectively deployed, maintained and supported across RCS clients for operational and reimbursement efficiency.

The Payer Operations & Intelligence Specialist is responsible for independently managing and optimizing payer-related EDI transactions, insurance plan structures, and operational workflows across the RCS division. The role applies advanced analytical and problem-solving skills to ensure payer configurations, and reimbursement outcomes are aligned with regulatory requirements and company objectives. The Specialist exercises independent judgment in evaluating payer changes, interpreting industry changes, and implementing solutions to improve operational efficiency and financial performance. This position serves as a subject matter expert and collaborates cross-functionally with Client Engagement, Operations, the EDI division, Product Management, Marketing, and external stakeholders to drive process improvements and ensure effective deployment of payer-related services.

Key Responsibilities:

• Independently manage and oversee provider EDI enrollment for electronic claims, remittance, and eligibility on behalf of clients, collaborating directly with internal departments to ensure accuracy, compliance, and timely implementation.
• Analyze and maintain insurance plan configurations, including eligibility verification logic, plan code mapping, claim population, submission workflows, and adjudication processes.
• Evaluate and communicate changes to payer requirements, regulations, and the impact of these changes on the billing operations to internal stakeholders and clients in a clear and actionable manner.
• Investigate and resolve complex transactional issues related to claims, remittance, eligibility, and claim status, exercising independent judgment to determine appropriate solutions.
• Identify opportunities to improve workflows, reduce errors, and enhance reimbursement outcomes through data-driven analysis and process improvement initiatives.Implement necessary updates and solutions within the payer configurations for transaction processing.
• Validate daily claim and remittance processing against established controls, identify discrepancies, and take corrective action as needed.
• Maintain the company’s electronic eligibility verification service and associated insurance plan code mappings by assessing eligibility response and billing requirements, collaborating on such with product engineers, Client Engagement, Operations and clients to enhance system functionality and performance.
• Provide subject matter expertise to Client Engagement, Operations and clients on EDI transaction edits (e.g., 270/271, 837, 835), and processing, collaborating with the EDI division to ensure optimal processing.
• Represent the RCS division in the Company’s monthly Insurance Committee Meeting and other cross-functional meetings, contributing insights and recommendations that influence business decisions ensuring divisional interests are appropriately represented.
• Other duties as assigned.

Education/Experience:

• Associate’s degree in healthcare administration, business administration, or equivalent experience with a preference for a four-year bachelor’s degree;
• Experience in healthcare revenue cycle, insurance billing and/or EDI transactions is preferred;
• Proficient with Microsoft Excel and Word;
• Experience managing multiple complex projects and priorities in a fast-paced, evolving environment;
• Demonstrated ability to exercise independent judgment and make decisions affecting operational outcomes.

Knowledge, Skills & Abilities:

• Strong analytical, critical thinking, and problem-solving skills;
• Excellent interpersonal, communication, and cross-functional collaboration skills;
• High attention to detail with a strong focus on accuracy and process improvement;