JOB DESCRIPTION:
The Claims EDI Operations Specialist is responsible for managing the technical and administrative lifecycle of claims data, with a primary focus on Electronic Data Interchange (EDI) transactions. This role serves as the technical liaison between the Claims team, IT, and external trading partners, ensuring the accuracy of 834, 835, and 837 file transmissions. In partnership with Claims Leadership, this specialist identifies, evaluates, and optimizes claims workflows, data integrity, and system performance.

Responsibilities and Duties:
Responsibilities include, but are not limited to the following:
EDI & Data Management (Core Focus)

• Manage the end-to-end lifecycle of EDI transactions (834/835/837), including file programming, validation, output, and error resolution.
• Serve as the primary liaison for trading partners, clearinghouses, payers, and vendors to troubleshoot transmission failures and rejection codes.
• Manage file generation and uploads and ensure compliance with x12 formatting standards.
• Research, analyze, and resolve data discrepancies between output files and source systems.
• Validate file layouts and mappings, against companion guide requirements.
• Ensure strict compliance with HIPAA x12 standards, CMS guidelines, and internal data policies.

Process Improvement & Implementation

• Lead testing and validation for new trading partner implementations or system upgrades.
• Document business requirements for implementations, system enhancements, or new trading partners.
• Monitor post-go-live implementations for data accuracy and coordinate required corrections.
• Develop and maintain comprehensive desktop procedures, job aids, and EOP insert revisions for new or changed processes.
• Develop testing schedules and accountabilities, documenting results and lessons learned.
• Perform time studies within the claims department to identify bottlenecks and document process steps.

Operational Support & Reporting

• Act as the liaison between Reporting/Data Analytics and Claims Management to drive reporting enhancements.
• Maintain and distribute Claims Dashboards (Trends/Patterns) by the 5th of the month.
• Develop and maintain GURU Claims Dashboard and Cards; generate reporting on usage and ROI.
• Oversee Symkey Daily Robot Checks and monitor automation performance.
• Train Claims Staff on Standard Policies and Procedures regarding data handling.
• Maintain Desktop Procedures for Payor Audits.
• Distribute operational reports to internal and external stakeholders.

Qualifications:

Education & Experience

• Associate's or bachelor's degree in healthcare administration, Information Technology, or related field preferred (or equivalent technical experience).
• 3+ years of EDI experience specifically with 834 (Enrollment), 835 (Remittance), or 837 (Claim) transactions required.
• 3-5 years Medicare/Medicaid claims experience required.

Technical Skills

• Advanced proficiency in Microsoft Excel (VLOOKUP's, pivots).
• Proficiency of SQL and database querying.
• Develop and maintain complex SQL queries, stored procedures, views, and data transformations using Microsoft SQL Server.
• Develop, maintain, and troubleshoot SSIS packages supporting ETL, claims processing, and EDI workflows.
• Trace data from source systems through SQL/SSIS processes to final EDI output and identify data discrepancies or processing issues.

Proven Personal Attributes:

• Analytical Mindset: Excellent data analysis skills with the ability to review data to identify trends, anomalies, and opportunities.
• Communication: Excellent oral and written communication skills; capable of explaining technical issues to non-technical stakeholders.
• Autonomy: Highly self-motivated and capable of working independently to follow issues through to conclusion.
• Organization: Detail-oriented with the ability to prioritize tasks in a fast-paced environment.
• Confidentiality: Ability to maintain a high level of confidentiality and remain HIPAA compliant.
• Ability to multitask in a fast-paced work environment.
• Ability to remain calm under pressure and manage stressful situations.
• Ability to maintain a high level of confidentiality and remain HIPAA compliant.
• Ability to establish highly productive and detailed organizational skills/habits.
• Ability to actively listen and solve problems with cooperation, assertiveness, and flexibility for positive outcomes.
• Possess strong, professional written and oral communication skills for in-person, telephonic, and electronic use.