EDI Specialist

THE SPECS.

• Non-Exempt.
• Full-Time.
• Experienced position.
• Benefit-Eligible: PTO, PSL, Holidays, Medical, Dental, Vision, Life Insurance, etc.
• Hybrid: Remote & In-office.
• Wage Range: starting $25+, based on experience.

THE POSITION.

The EDI Specialist has a vital role within the healthcare administration industry. It is responsible for managing the electronic data interchange (EDI) process for claims submissions and ensuring accurate and timely processing of claims. This position requires strong technical skills, attention to detail, and knowledge of healthcare industry standards. The EDI Specialist works closely with internal teams, external partners, and healthcare providers to facilitate seamless claims processing and resolve any issues related to EDI transactions. This position needs to have previous experience in dealing with EDI in a managed care industry and encounter data.

KEY RESPONSIBILITIES.

EDI Management:

• Monitor and manage the EDI system for claims submissions, ensuring smooth transmission of data between the health plan and healthcare providers.
• Troubleshoot and resolve any EDI-related issues, including rejected or denied claims, formatting errors, and data discrepancies.
• Collaborate with IT teams and vendors to maintain and enhance the EDI infrastructure and resolve technical issues.
• Manage encounter data and reporting.

Claims Processing:

• Review and validate incoming claims data received through EDI to ensure accuracy, completeness, and compliance with industry standards and regulations.
• Identify and resolve any data discrepancies or missing information, working closely with healthcare providers to obtain necessary details.
• Process and adjudicate claims accurately and efficiently, following established guidelines and protocols.
• Conduct quality assurance checks on processed claims to minimize errors and ensure compliance with internal policies and regulatory requirements.

Relationship Management:

• Build and maintain strong working relationships with healthcare providers, EDI clearinghouses, and other external partners to facilitate effective claims processing and issue resolution.
• Collaborate with internal teams, including claims operations, customer service, and IT, to address provider inquiries, resolve EDI-related issues, and improve overall claims processing efficiency.

Compliance and Reporting:

• Stay up to date with industry standards, regulatory requirements, and best practices related to EDI in healthcare administration or health plan industry.
• Ensure adherence to HIPAA regulations and other privacy and security guidelines while handling sensitive claims data.
• Generate regular reports on EDI transaction volumes, claim processing metrics, and performance indicators to track trends, identify areas for improvement, and support decision-making processes.
• Process Improvement:
• Identify opportunities to streamline and optimize the claims EDI process, leveraging technology, automation, and industry best practices.
• Work collaboratively with cross-functional teams to implement process improvements, system enhancements, and workflow changes to enhance efficiency and accuracy.

Other duties as assigned.

IMS offers competitive compensation depending on experience. We are an equal opportunity employer and seek diversity in our workforce. IMS is also an E-Verify Employer. To learn more about E-Verify and your rights and responsibilities, please visit: https://www.e-verify.gov/employees/employee-rights-and-responsibilities .

EDUCATION :

• Bachelor’s degree in healthcare administration, business, information technology, or a related field (or equivalent experience).

EXPERIENCE:

• Minimum of 3+ years of experience in similar position in a healthcare administration, IPA, MSO, and/or health plan setting.
• Strong experience with databases and software systems, EDI standards and protocols, and other relevant healthcare industry standards.
• Experience with coding systems, such as CPT, ICD-10, and HCPCS, and other applications regarding claims processing.
• Experience in troubleshooting and resolving EDI-related issues, including rejected or denied claims, formatting errors, and data discrepancies.
• Experience in generating reports, analyzing data, and using performance metrics to drive process improvement initiatives.
• Familiarity with project management principles and the ability to lead or contribute to process improvement projects.
• Experience with handling encounter data and understanding contracts and benefits of managed care services.

SKILLS/KNOWLEDGE/ABILITIES

• Strong understanding of healthcare claims processing, EDI standards (such as ANSI X12 and HL7), and relevant regulatory requirements (HIPAA, CMS guidelines, etc.).
• Proficiency in EDI tools and software, including experience with claims management systems, clearinghouse platforms, and data mapping/validation tools.
• Excellent analytical and problem-solving skills, with an attention to detail and ability to manage multiple priorities in a fast-paced environment.
• Effective communication and interpersonal skills, with the ability to collaborate and build relationships with internal and external stakeholders.
• Strong organizational and time management abilities, with a focus on meeting deadlines and delivering high-quality work.
• Knowledge of coding systems, such as CPT, ICD-10, and HCPCS, and their application in claims processing is desirable.
• Familiarity with healthcare payer operations and understanding of revenue cycle management is an advantage.
• Healthcare knowledge of HIPAA regulations and other privacy and security guidelines related to handling sensitive claims data and PHI.
• Strong analytical and problem-solving skills, with the ability to identify patterns, trends, and areas for process improvement.
• Ability to work in a fast-paced, deadline-driven environment while maintaining a high level of accuracy and attention to detail.
• Knowledge of healthcare industry trends, regulatory changes, and emerging technologies related to EDI in claims processing.

*Please note that the duties and responsibilities outlined above are summarized and may not encompass all tasks associated with the position. The nature of the role may require adaptation to changing circumstances and additional responsibilities not explicitly mentioned here. The organization reserves the right to modify, interpret, or supplement the job duties as needed.