EDI Specialist

Job Summary:

The EDI Specialist works with the company’s Electronic Data Interchange program, facilitating the establishment of new customer/partner relationships within our EDI environment, including documenting requirements, testing solutions, and ensuring successful implementations.

Duties and Responsibilities

• Monitor generation and transmission of both inbound and outbound EDI data; perform initial troubleshooting on all processes to resolve content issues and map problems.
• Review/log failures, resolve data issues, and reload data. Collaborate with other departments as needed.
• Pull and load files for non-automated processes.
• Maintain EDI status tracking; prepare reports of results.
• Maintain active relationships with internal and/or external stakeholders to develop business requirements.
• Participate in meetings with stakeholders to gather and document requirements and explore potential solutions.
• Work with development team to develop, define application scope and objectives and prepare functional and/or technical specifications to accommodate business processes related to EDI.
• Analyzes and classifies complex change request and identifies and documents possible system code enhancements.
• Conduct and lead on all end-to-end testing phases with Trading Partners and Business Users.
• Assist in creating basic test scenarios to be used in testing the business applications in order to verify that client requirements are incorporated into the system design.
• Identify, recommend, and implement process improvements in support of the EDI system.
• Perform root cause analysis of any production issue and generate solutions to prevent recurrence.

Required Knowledge, Skills, and Abilities:

• Bachelor’s degree in computer science, mathematics or informatics or equivalent experience.
• 3 years of EDI health care transaction processing for eligibility, clinical, claims, accumulator & provider X12 data.
• 10+ years of healthcare insurance industry claims and eligibility administration experience preferred.
• Direct / Hands-on experience with EDI Healthcare X12 Transactions (837, 834, 835, 270/271, 278, 276/277, 999).
• Knowledge of industry standard health data code sets such as ICD-10, CPT/HCPCS, revenue codes.
• Knowledgeable with regulatory requirements associated with 5010 and ICD-10.
• Specific knowledge of claims, enrollment, and /or Authorizations.
• Knowledge of Agile Methodology.
• SQL/DB management environments including Microsoft SQL Server and PostGREsql databases.
• Eldorado Javelina claims management platform experience a plus.
• Solid working knowledge of standard computer applications including MS Word, Excel, Outlook, and PowerPoint.
• Communicate clearly and professionally with internal and external customers; including the ability to explain technical detail with non-technical counterparts.
• Work effectively as part of a team to achieve established outcomes. Understand other’s roles and empower one another to take responsibility to be successful. Demonstrate a collaborative interaction with peers to reach a common goal.
• Demonstrate a collaborative interaction with peers to reach a common goal as well as be a resource to team members and internal/external customers.
• Pay close attention to detail in all aspects of the job.
• Make decisions using available resources and sound judgment.
• Maintain confidentiality and discretion.
• Identify and resolve problems in a timely manner, gather and analyzes information skillfully.
• Open to other’s ideas and exhibits a willingness to try new things.
• Demonstrate accuracy and thoroughness; monitor work to ensure quality.
• Prioritize and plan work activities to use time efficiently.
• Adapt to changes in the work environment, manage competing demands; able to deal with frequent change, delays, or unexpected events.
• Follows instructions, responds to direction, and solicits feedback to improve.
• Act in such a way to instill trust from management, other associates, as well as customers.  

Physical Demands - The physical demands described here are representative of those necessary for an employee to successfully perform the essential functions of this job. Reasonable accommodation can be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is required to talk and hear. The employee will have prolonged periods of sitting at a desk and working on a computer. The employee may be required to lift/carry objects of up to 20 pounds. The employee is also required to have better than average dexterity to use hands to, handle, or feel; and reach with hands and arms. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception, and ability to adjust focus.

Work Environment - The work environment described is representative of what must be met by an employee successfully perform the essential functions of this job.

• The physical environment is indoors in a controlled climate, office setting. The noise level may be low to moderate.

The duties described are representative, but not restrictive of tasks that may be assigned or of the abilities required to do the job. The description is subject to change at any time. Other related duties may be assigned. This description does not alter the at-will status of employment.

Pay may vary based on location. Offers will be adjusted based on an individual's experience, education, and other job-related factors as permitted by law.