- Provide analysis, support and guidance to both internal and external clients on complex electronic data transfers covering enrollment, claims, billing, and payments.
- Import and export files using FTP/SFTP software.
- Research and interpret ANSI X12 files from various sources; including format types 837, 835, 834, 278, and 999.
- Communicates with payers for clarification and resolution on rejections, denials, and eligibility requirements.
- Troubleshoot with internal teams, clients, providers, and external vendors to resolve EDI related issues, to include mapping and similar configuration items.
- Work with the claims team to create reports of common entry errors to perform frequent audits of data loaded to ensure accuracy.
- Create reports for enrollment reconciliation, claim rejections, total count by vendors, and identify report discrepancies.
- Create and modify data mappings when necessary.
- Manage multiple EDI Implementations and maintain communication with clients and vendors
- Acts as a Subject Matter Expert and escalation specialist regarding problems or situations within the EDI team.
- Participates in new product launches, special projects, and performs additional duties as needed.
- Work collaboratively with implementation teams and third-party vendors to perform support configuration functions to ensure:
- Institutional or professional contracts are properly loaded into internal or vendor processing systems through appropriate research and provider data load activities.
- Resolve third-party vendor load issues within established documented processes.
- Proper supporting documentation exists, is updated, and maintained on file for all load processes.
- Assists in updating payable procedure codes, price rules and fee schedules.
- Bachelor's degree in information technology, computer science, or related field experience.
- 2 years of Healthcare experience.
- 2 years performing EDI-related work.
- Experience with of X12 EDI Standards and HIPAA requirements.
- Experience with clearinghouses such as Waystar, Emdeon, Zirmed, and Availity.
Other Desired Qualifications
- Experience with SQL Server and Process Automation.
- Manage Care experience.
- Bilingual (English and Spanish).
The EDI Jr. Specialist is expected to perform all aspects of the position with additional responsibilities as needed. Must be able to work both independently and in teams and must be self-directed. Must works well under pressure and multitasks in an interrupt-driven environment.
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