EPIC - PB Claims Analyst (Claims Certification)

The Professional Billing (PB) Claims Analyst is responsible for the design, build, maintenance, and optimization of system claims processing logic and workflow engines within the Electronic Health Record (EHR) environment (e.g., Epic Resolute PB and Claims). This role is primarily focused on claim statusing (including 276/277 transaction workflows, clearinghouse integration, status workqueues, and real-time status inquiry), ensuring claims move seamlessly through adjudication to clean submission and rapid reimbursement. The ideal candidate must possess an active, vendor-verified Claims Certification (e.g., Epic Claims Certification) along with deep, hands-on claims build expertise-including Claim Definitions (CDF), custom validation rules, routing logic, and clearinghouse interface management.

Key Responsibilities Claim Statusing & Adjudication Workflows Build, maintain, and configure automated claim statusing workflows utilizing ANSI ASC X12 EDI standard transactions (276 Claim Status Request / 277 Claim Status Response). Configure clearinghouse integration rules, claim acknowledgment (999/277CA) ingestion, and third-party payer statusing bridges. Construct and refine Account and Claim Status Workqueues (WQ) with automated routing rules to ensure operational teams focus strictly on actionable, rejected, or unacknowledged claims. Analyze statusing lag times, unacknowledged submissions, and payer-specific response trends to optimize follow-up cadences and minimize Days in Accounts Receivable (A/R). Claims Engine Configuration & Build Perform end-to-end technical configuration and ongoing maintenance of the enterprise Claims build, Claim Definition files (CDF), and payer-specific output formats (CMS-1500 / 837P). Build and update claim edit rules, error-checking logic, and validation criteria to drive first-pass clean claim submission rates. Manage payer ID mapping, provider credentialing mapping/overrides, taxonomy crosswalks, and Revenue Module Object (RMO) billing rules. Conduct thorough unit testing, system integrated testing, and end-to-end validation for all new claims build, regular system upgrades, and annual regulatory/payer updates. Root-Cause Analysis & Revenue Cycle Optimization Partner with Central Billing Office (CBO), Patient Financial Services (PFS), and Revenue Integrity teams to conduct root-cause analysis on pre-bill edits, clearinghouse rejections, and post-submission denials. Convert operational denial trends and recurring manual touchpoints into automated front-end claim edits or automated statusing rules. Troubleshoot complex claims interface errors, translation failures, and EDI engine script anomalies. Develop documentation, build trackers, and workflow specifications for change control, audits, and operational training.

Required Qualifications Certification: Active vendor Claims Certification is REQUIRED (e.g., Epic Claims Certification / Resolute Claims Administration). Note: Dual certification in Resolute Professional Billing / PB Admin is strongly preferred.

Experience: Minimum of 3 5+ years of hands-on technical build and configuration experience within healthcare revenue cycle applications, with direct ownership of PB claims engine workflows. Technical Depth: Proven expertise in building Claim Definitions (CDF), Claim Logic Rules, 837P EDI formatting, and claim edit workqueue configuration. EDI & Statusing Mastery: Extensive practical experience with EDI transaction standards, specifically 276/277 claim statusing, 837P claim generation, and 835 payment remittance integration.

Education: Bachelor's degree in Healthcare Information Systems, Computer Science, Business Administration, or equivalent relevant professional experience.

Preferred Qualifications Additional certification in Epic Resolute Professional Billing (PB) Administration or Epic Charge Router. Experience working directly with healthcare clearinghouses (e.g., Optum/Change Healthcare, Experian Health, Waystar, Availity). Solid background in Single Billing Office (SBO) workflows and cross-application integration with Hospital Billing (HB) and Cadence scheduling. Proficient with relational database reporting (SQL, Epic Reporting Workbench, or Radar Dashboards) to monitor claims throughput and WQ health. Skills & Competencies Technical Acumen: Ability to translate complex payer reimbursement and billing policies into functional system rules and automated triggers. Analytical Problem-Solving: Rigorous attention to detail when debugging EDI syntax, clearinghouse transmission logs, and data mapping mismatches. Collaboration & Communication: Capacity to translate technical build constraints into plain-language guidance for billing operations and leadership.

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Background Check : No

Drug Screen : No