EDI Specialist

Essential Duties

• Serve as the organizational subject matter expert for all EDI-related processes, technologies, and electronic transaction workflows.
• Administer and maintain payor enrollments for Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT), ensuring timely implementation and ongoing accuracy.
• Monitor and optimize ERA enrollment performance to maintain a target of 95% or greater electronic payment posting across all eligible payors.
• Manage user access and security for payor portals, clearinghouses, and other electronic transaction platforms, ensuring appropriate governance and compliance.
• Monitor EDI transaction activity and proactively identify, troubleshoot, and resolve transmission failures, processing errors, and connectivity issues.
• Oversee clearinghouse performance, including claim transmission, payer routing, edit management, acknowledgements, and transaction acceptance rates.
• Analyze claim exceptions, rejections, and electronic edit trends to identify root causes and implement scalable, long-term solutions that improve first-pass claim acceptance.
• Evaluate payor configurations and billing system setup to ensure accurate electronic routing, reduce technical denials, and improve payment turnaround times.
• Develop, document, and maintain EDI workflows, technical procedures, standard operating procedures (SOPs), and system documentation.
• Partner with Information Technology and external vendors to implement new EDI connections, optimize interfaces, test system enhancements, and support software implementations.
• Continuously evaluate opportunities to expand automation, improve electronic transaction utilization, reduce manual intervention, and enhance operational efficiency.
• Monitor electronic transaction metrics, payer performance, enrollment status, and processing trends, providing actionable reporting and recommendations to leadership.
• Collaborate with Revenue Cycle, Coding, Billing, Provider Enrollment, and Managed Care teams to resolve payer connectivity issues and improve reimbursement outcomes.
• Assist with the identification, investigation, and resolution of payments issued to incorrect providers, addresses, or banking information, coordinating corrective actions with payors and internal stakeholders.