Senior Health Care EDI Specialist

#### Company Overview:

Client is at the forefront of healthcare automation, specializing in leveraging AI and Robotic Process Automation (RPA) to revolutionize revenue cycle management (RCM) for hospitals, physician groups, healthcare payers, and medical billing companies. Our solutions empower healthcare organizations to optimize financial performance, reduce operational inefficiencies, and... enhance patient care. We pride ourselves on our best-in-class technology, which seamlessly integrates with existing systems to deliver significant improvements in cash flow, claim processing, and compliance.

Skills:

Skills: Healthcare EDI, Revenue Cycle Management (RCM), Robotic Process Automation (RPA), Claims Processing (837, 835, 270/271), Eligibility Verification, Pre-Authorization Automation, HIPAA Compliance, SOC 1 & SOC 2 Compliance, Healthcare IT, Payment Posting Automation, Business Intelligence (BI) Analytics, Predictive Analytics, Data Security, Medical Billing Systems, Healthcare ERP (Plex, Epic, Cerner, Athenahealth), Automation Implementation, Problem Solving & Troubleshooting, Project Management, Process Optimization, Accounts Receivable (A/R) Management.

#### Position Summary:

The **Senior Health Care EDI Specialist** will play a pivotal role in the design, implementation, and management of complex EDI systems, supporting Client s healthcare automation initiatives. This position requires extensive expertise in handling EDI integrations for hospitals, payors, physician groups, and medical billing companies, focusing on optimizing revenue cycle processes through automation. The successful candidate will collaborate with cross-functional teams to ensure seamless data flow, error-free transaction processing, and high levels of compliance in a rapidly evolving regulatory landscape.

#### Key Responsibilities: ? **EDI Strategy & Management:** Lead the development, implementation, and maintenance of EDI systems to support RCM initiatives across multiple healthcare organizations, including hospitals, physician groups, and payors. ? **Complex EDI Integration:** Spearhead the integration of Client s AI-driven RPA solutions with existing healthcare systems for claims processing (837), remittance advice (835), eligibility verification (270/271), and acknowledgments (999/997). ? **Advanced Automation Solutions:** Collaborate with the AI and RPA teams to develop and enhance automated solutions that streamline complex EDI processes, improving accuracy by 99% and reducing manual interventions by 70%. ? **Claims Management & Payment Posting:** Utilize cutting-edge automation technologies to enhance claims status follow-up, payment posting, and revenue collection efforts, achieving 400% faster processing times compared to traditional methods. ? **Eligibility Verification & Pre-Authorization:** Oversee the integration of automated eligibility verification and pre-authorization systems capable of handling 300 eligibility checks per minute, reducing denial rates by up to 70%. ? **Data Analytics & Reporting:** Leverage proprietary business intelligence (BI) and predictive analytics tools to provide insights into RCM performance, transaction efficiency, and financial outcomes. ? **Compliance & Regulatory Management:** Ensure full compliance with healthcare industry standards, including HIPAA, SOC 1, SOC 2, and PCI. Implement and monitor data security protocols to protect sensitive patient and financial information. ? **Issue Resolution:** Provide expert-level support to troubleshoot complex EDI transaction errors, delays, or discrepancies, ensuring timely resolution and system optimization. ? **Stakeholder Collaboration:** Work closely with RCM, IT, and external stakeholders (including clearinghouses, payors, and providers) to design custom EDI solutions that meet the specific needs of healthcare organizations. ? **Process Innovation & Optimization:** Continuously identify opportunities to improve operational efficiency and data accuracy through the innovative use of RPA, AI, and EDI technologies, driving a 25% increase in revenue realization and a 20% reduction in bad-debt write-offs.

#### Qualifications: ? **Education:** Bachelor s or Master s degree in Information Technology, Healthcare Administration, Computer Science, or a related field. Equivalent professional experience may be considered. ? **Experience:** ? 8-10 years of experience in healthcare EDI management, RCM, or healthcare IT, specifically within complex environments such as hospitals, health systems, or large physician groups. ? Deep expertise in handling large-scale EDI transactions, including 837 (claims), 835 (remittance), 270/271 (eligibility), 999/997 (acknowledgments), and 276/277 (claims status). ? Proven track record of working with healthcare ERP systems, such as Plex by Rockwell Automation, and RCM platforms like Epic, Cerner, or Athenahealth. ? Extensive experience implementing and optimizing AI-driven RPA solutions for automated claim processing, eligibility verification, and payment posting. ? **Skills:** ? Exceptional understanding of HIPAA, SOC 1, SOC 2, and PCI compliance requirements, with a focus on data security in healthcare transactions. ? Strong analytical and problem-solving skills, with the ability to interpret complex data sets and deliver actionable insights for process improvements. ? Expertise in working with automation and AI tools to reduce manual interventions, increase accuracy, and drive operational excellence in healthcare RCM. ? Strong leadership and project management capabilities, with experience leading cross-functional teams in complex healthcare technology implementations. ? Superior communication and interpersonal skills to collaborate with internal and external stakeholders at all levels.

#### Preferred Qualifications: ? Experience with large-scale healthcare consolidation efforts, including integration of independent and hospital-based physician groups. ? Familiarity with advanced analytics, data visualization tools, and decision-support systems within healthcare RCM. ? Prior experience in implementing cash acceleration strategies to optimize accounts receivable and improve cash flow for healthcare organizations.

Note: This is for freelancing/talent on-demand basis

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