Hybrid Compliance and EDI Analyst bei Arch Capital Group Ltd.

The Shared Services Team is seeking a new team member who thrives in a highly collaborative team oriented environment.  The Compliance and EDI Analyst position is a hybrid role that requires support in two distinct area’s.  You will be supporting the Claims Division with all facets of Medicare and SCHIP reporting processes and assistance with general claims compliance requirements (as needed). This EDI aspect role involves ensuring data accuracy, compliance with state regulations, and the efficient processing of claims information.  The ideal candidate will have strong analytical skills and experience with EDI systems.  The position will also require knowledge of Medicare regulations and reporting procedures, with a focus on ensuring compliance and optimizing reporting accuracy.  The candidate will collaborate with internal teams to improve operations and enhance client satisfaction.

Primary Job Duties & Responsibilities

• Compliance Responsibilities:
  • Meet the Compliance Guidelines of CMS (Centers for Medicare Services) through knowledge of “5 Fields” for eligibility determination; as well as ICD Codes, TPOC (Total Payment to Claimant) and ORM (Ongoing Responsibility for Medial)
  • Maintain a close relationship with vendor partner to access reports and data in vendor dashboard and MSP Navigator tool.
  • Complete Missing Section 111 data, compare missing eligibility information to RMA
  • Monitor CP Link, present claims for review when necessary, forwarding and following up on Treasury Notices with Examiners.
  • Address any CMS alerts that arise.
  • Update Arch’s CMS/SCHIP Policies & Procedures Manual and Workflows as needed.
  • Assist Compliance team with other aspects of Claims Compliance as necessary.
• Workers Compensation EDI Responsibilities:
  • Ensure compliance with federal and state workers’ compensation regulations and EDI standards
  • Monitor and troubleshoot EDI submissions, addressing errors and discrepancies or issues promptly
  • Collaborate with internal teams, including claims adjusters and IT, to improve reporting processes
  • Maintain documentation and records related to EDI processes and submissions
  • Provide training and support to team members regarding EDI reporting practices
  • Keep up-to-date with changes in EDI standards and workers’ compensation regulations
  • Analyze, compile, and report on Medicare data to ensure compliance with regulations and internal standards
  • Maintain reporting tools and templates for efficient data analysis
  • Collaborate with operational teams to gather data and provide insights on Medicare eligible claims
  • Stay updated on changes in Medicare policies and regulations, advising the team on impacts
  • Provide training and support to team members regarding Medicare reporting practices
  • Identify trends and discrepancies in data and collaborate on resolutions strategies
  • Generate performance metrics and dashboards for internal stakeholders

Qualifications

• Bachelor's degree preferred.
• IAIABC Certification required.
• In-house and insurance/reinsurance experience; either or both preferred
• Minimum of one year plus experience working preferably with insurance compliance issues or equivalent.
• Hands-on experience and strong aptitude with Microsoft Excel, PowerPoint and Word
• Exceptional communication (written and verbal), influencing, negotiating, listening, and interpersonal skills to effectively develop productive working relationships with internal/external peers and other professionals across organizational lines
• Strong problem-solving, analytical, organizational, and time management skills
• Advanced attention to detail ensuring work product accuracy
• Applies critical thinking and produces information to identify key issues

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