Veradigm is an innovative Healthcare Analytics and Technology Company that delivers visibility and transparency for Risk Adjustment and Quality Management programs. We enable health plans and at-risk providers to achieve the greatest financial impact in the Health Insurance Exchange (HIX), Medicare Advantage, and Medicaid markets. By combining advanced analytic methodologies with extensive health plan experience, Veradigm has developed a suite of uniquely pragmatic solutions that are revolutionizing risk adjustment. Veradigm flexible business intelligence tools offer real-time visibility into member and provider activities so our clients can apply the most cost-effective and appropriate interventions for closing gaps in documentation, coding, and quality.

Job Summary

Join the Payer Team as a System Analyst, providing expert support to BPO clients in managing claims submissions. In this role, you’ll serve as a critical liaison between client teams and internal systems, ensuring seamless communication and operational alignment. Success requires deep knowledge of ACA-related data workflows, Medicare and Medicaid programs, and healthcare technology platforms. You’ll apply your technical expertise in requirements gathering, gap analysis, data mapping, and SQL to support accurate and compliant claims processing. A strong understanding of claims file structures and submission protocols is essential, along with the ability to quickly identify and resolve issues. This role demands ownership, adaptability, and clear, confident communication to guide clients through complex data challenges.

Key Responsibilities

Inbound Source File Oversight

• Monitor and manage inbound files placed on FTP servers.
• Upload client files into internal systems, ensuring timely receipt per established schedules.
• Validate file volume against claim estimates and enrollment figures.
• Track missing or failed files and support RCA for upload issues.

Escalation and Collaboration

• Collaborate with internal SMEs and client teams to escalate UI discrepancies.
• Attend client calls to provide updates, clarify issues, and support resolution efforts.
• Contribute to process improvement through documentation updates and feedback loops.

Data Validation & Edits

• Manage duplicate records and versioning logic.
• Review and correct validation errors using system-generated reports.
• Redirect unrepairable errors to clients for correction in source systems.
• Partner with clients to interpret record-level guidance when needed.

Encounter & Supplemental File Submission

• Identify records eligible for submission.
• Generate and submit encounter and supplemental files to CMS.
• Maintain audit trails for all submissions and resubmissions.
• Resubmit failed files based on CMS response feedback.

Response & Report File Management

• Load and process CMS response files.
• Manage post-submission errors and apply mitigation tactics.
• Flag and mark unrepairable records to support quality and statistical reporting.

Risk Analysis & Reporting

• Analyze gaps in claims data and validate alignment with SOW scope.
• Extract and interpret dashboard and report data for internal and client use.
• Recommend best practices based on data trends and RCA findings.

Qualifications

• Bachelor’s degree in health information management, Data Analytics, or a related field.
• 2+ years’ healthcare technology industry experience
• 2+ years' experience working with ACA and Medicare/Medicaid programs
• Familiarity with CMS/ACA submission protocols and 837 file formats
• Experience with ACA Edge Server environments, including validation
• Strong analytical skills and attention to detail.
• Experience with FTP, data validation tools, and ticketing systems (e.g., JIRA, ServiceNow).
• Excellent communication and client-facing skills
• Demonstrates initiative
• Takes ownership of responsibilities
• Ability to Follows up to ensure tasks are completed
• Proactively seeks clarification to ensure full understanding
• Confident in posing thoughtful, sometimes difficult questions to address gaps or surface critical issues.

Preferred Skills

• Knowledge of PHI handling and HIPAA compliance.
• Experience with Medicare Advantage or Medicaid encounter data.
• Ability to interpret Statements of Work (SOWs) and translate into operational workflows.
• Proficiency in Excel, SQL, or data visualization tools.