EDI Specialist

Summary / Objective:
The EDI Specialist is responsible for the end-to-end management, monitoring, and optimization of electronic data interchange (EDI) transactions supporting healthcare claims processing, enrollment, encounter submissions, and financial remittance. This role ensures accurate, timely, and compliant data exchange between clearinghouses, providers, health plans, and regulatory entities (e.g., CMS), including responsibilities aligned with delegated claims processing and Medicare Advantage requirements. The position plays a critical role in maintaining data integrity, supporting downstream reporting and encounter submissions, and ensuring compliance with HIPAA X12 standards, CMS regulations, and trading partner requirements.

Essential Functions:

EDI Operations & Monitoring
•    Monitor, validate, and process inbound and outbound EDI transactions (e.g., 837, 835, 834, 277CA, 999) 
•    Validate file transmission schedules and ensure timely receipt and delivery of EDI files 
•    Track day-to-day EDI and batch processing activity to ensure operational continuity
•    Contribute to shifting processes from manual/batch-heavy workflows toward more real-time or event-driven data exchange where appropriate.

Issue Resolution & Data Integrity
•    Troubleshoot EDI transaction issues, including format errors, validation failures, and data discrepancies 
•    Conduct SNIP-level validation troubleshooting and perform root cause analysis 
•    Resolve gaps in data flow and business communication across systems and trading partners

Trading Partner Onboarding & Testing 
•    Lead end-to-end EDI onboarding for new and existing trading partners 
•    Coordinate implementation plans with internal teams (e.g., compliance, operations, customer service) 
•    Develop, execute, and document test scripts for X12 EDI transactions 
•    Ensure transactions meet companion guide specifications and business requirements prior to production deployment

Compliance, Audit & Reporting
•    Ensure EDI processes comply with HIPAA X12 5010 standards and trading partner companion guides 
•    Support internal and external audit requests related to data integrity and interface controls
•    Develop and maintain EDI workflows, procedures, and process documentation 
•    Produce operational reporting and KPI analysis for leadership

Encounter Submission
•    Manage the end-to-end encounter submission process, including file preparation, validation, submission, and reconciliation 
•    Monitor encounter acceptance and rejection rates and coordinate resubmissions as needed 
•    Ensure alignment between claims adjudication outputs and encounter submission requirements

Continuous Improvement
•    Identify opportunities to improve EDI processes and reduce manual intervention 
•    Implement automation and workflow enhancements
•    Drive ongoing improvements to transaction processing and data quality
•    Create/review/update EDI documentation 
•    Participate in evaluating and improving current integration architecture to better support scalability, flexibility, and future state needs. 

Knowledge / Skills / Abilities:
•    Strong attention to detail and ability to manage highly regulated documentation with accuracy and consistency.
•    Clear written and verbal communication skills, audit support, committee documentation, and cross-functional collaboration.
•    Ability to interpret and apply X12 and regulatory standards.
•    Understanding of healthcare data integrity principles, including claims, eligibility, and enrollment data controls, and audit readiness expectations.
•    Strong organizational, time management, prioritization, and follow-through skills.
•    Proficiency with Microsoft Office Suite and Notepad