EDI Specialist

Description

Core Clinical Partners stands at the forefront of Emergency and Hospital Medicine, delivering unparalleled services through a model that emphasizes patient-centric care and operational excellence. Our corporate values – Genuine, Accountable, Dynamic, Respectful, and Fun – are the pillars that uphold our commitment to revolutionize healthcare delivery.

The Senior EDI Specialist serves as the organization's subject matter expert for Electronic Data Interchange (EDI), responsible for the strategic management, implementation, optimization, and governance of electronic data exchange across the Revenue Cycle Management (RCM) ecosystem. This role ensures the integrity, efficiency, and scalability of electronic transactions between providers, payors, clearinghouses, and internal systems.

The Senior EDI Specialist oversees payor connectivity, electronic remittance advice (ERA) and electronic funds transfer (EFT) enrollments, clearinghouse operations, user access management, and electronic transaction performance. Through proactive monitoring, process improvement, and cross-functional collaboration, this role drives operational excellence, enhances claim and payment automation, reduces denials, and improves overall revenue cycle performance.

Working closely with Revenue Cycle Management, Information Technology, Coding, Billing, Provider Enrollment, Data Integrity, Managed Care, and external technology partners, the Senior EDI Specialist identifies opportunities to improve system integrations, streamline workflows, ensure regulatory compliance, and maximize electronic transaction success.

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.
• Ensure compliance with HIPAA transaction standards, CMS requirements, and applicable federal and state regulations governing electronic healthcare transactions.
• Performs other related duties as assigned.

Skills, Knowledge, Abilities:

• Deep knowledge and understanding of professional claims processing and adjudication in the healthcare and health insurance industry.
• Well-versed in revenue cycle management compliance, claim edits, rejections, and loop and segment errors.
• Demonstrated knowledge of EDI document types: 837, 835, 834, 276/277, 270/271
• Advanced proficiency with Microsoft applications, including Word, Excel, and Outlook.
• Familiarity with relational databases (SQL) preferred.
• Strong organizational skills with the ability to multi-task in a fast-paced environment. 
• Ability to adapt, modify and prioritize while adhering to strict deadlines and a willingness to shift priorities to meet the needs of the organization. 
• Excellent communication and interpersonal skills and demonstrated ability to interact with a variety of team members.
• Demonstrated analytical and problem-solving skills with the ability to identify root causes and implement sustainable solutions.
• Self-motivated with the ability to identify opportunities for improvement and demonstrate the initiative to resolve issues in support of improvement efforts. 
• Strong analytical skills and the ability to work independently to analyze and solve problems. 
• Adept at learning proprietary software applications.
• Navigate competing priorities and effectively work in a fast-paced environment.
• Experience working with healthcare payors, enrollment processes, and vendor management.
• Exhibit growth mindset and team-orientated behaviors 

Requirements

Education:

Bachelor’s Degree in Information Technology, Computer Science or related field preferred but not required.

Experience: 

4+ years in EDI analytics, implementation, or healthcare revenue cycle management.

Proficiency in EDI standards, HL7, mapping (STTM), and integration tools; experience with payer, claims, benefits, and care management systems.

Healthcare industry experienced preferred.

Microsoft Excel experience in analyzing and organizing large volumes of data for trending/exception reporting.

Work Location:

Hybrid, preferred. If hybrid, the employee should be in the office a minimum of 3 days per week. The employee must have reliable access to internet when working remotely. 

Core Clinical Partners is an equal opportunity employer, drug-free workplace, and complies with ADA regulations as applicable.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.