EDI Consultant

EDI Consultant

Key Responsibilities:

• Conduct detailed reviews of

  837P (Professional) EDI transactions

  to ensure data integrity and format accuracy.
• Validate mappings to

  CMS-1500 claim forms

  , ensuring alignment between electronic and paper-based formats.
• Review and confirm correct population of provider fields (e.g.,

  Rendering NPI, Supervising NPI

  ) at both

  line-item

  and

  claim levels

  .
• Identify, document, and communicate any

  gaps, mismatches, or inconsistencies

  between system-generated data and payer requirements.
• Collaborate with cross-functional teams (EDI developers, business analysts, QA) to provide feedback and recommend corrections.
• Participate in user acceptance testing (UAT) and post-deployment validation to ensure implementation success.
• Stay updated on HIPAA EDI standards and payer-specific guidelines related to 837P/CMS-1500 submissions.

Required Qualifications:

• Proven experience working with

  837P transactions

  and

  CMS-1500

  claim formats.
• Strong understanding of

  HIPAA EDI standards

  , claim data elements, and provider field logic.
• Hands-on experience with claim validation tools, EDI mapping, and system configuration review.
• Familiarity with payer-specific submission requirements and business rules.
• Ability to analyze large data sets and identify discrepancies or issues efficiently.
• Excellent documentation, communication, and collaboration skills.

Preferred Qualifications:

• Experience with clearinghouses or payers.
• Familiarity with 837I or other transaction sets (e.g., 835, 999, 277CA).
• Prior work with EHR/EMR or billing system integrations.