Electronic Data Interchange (EDI) Claims Specialist  

Oversee the initial stages of claim handling ensuring that all submitted claims meet the required formatting and compliance standards before adjudication.

Ensure proper mapping and formatting of claims data for system compatibility.

Upload and validate EDI claim files (e.g., 837 format) from providers and clearinghouses

Ensure that the claims uploaded by providers or clearinghouses either through clearinghouses or direct SFT connections are properly received and routed to the appropriate internal processing systems for review and validation.

Ensure that all received inbound EDI transactions are submitted for EDI processing in system.

Monitor EDI transmission logs and resolve upload errors in coordination with MIS.

Maintain detailed records of processed EDI files and error resolutions in a similar Monitoring Log sheet maintained for paper claim submissions.

Confirm receipt and communicate the status of each claim, the EDI Claims Specialist facilitates the generation of standardized response files which includes:

• EDI 999 – Functional acknowledgement confirming the claim file was received.

• EDI 277CA – Claim status notification indicating whether the claim is accepted, rejected or pending.

• EDI 835 – Remittance advice detailing payment decisions and adjustments.

Ensure that Reject Reports are properly and timely transmitted to providers.

Communicate with internal departments and external partners regarding claim file status and discrepancies.

Assist in improving EDI workflows and documentation for operational efficiency.

Respond to inquiries related to EDI uploads and claim status.

Participate in the testing of EDI claims before deployment to production.

May be assigned to serve as back-up for Guam Claims Specialist and Claims Clerk ll.

Ensure participation in various company programs, activities and committees, such as but not limited to training and development programs, collegial planning, collaborative ad-hoc projects, and other company-sponsored events, as necessary.

Adhere to all set Organization policies, procedures and standards, and promote culture of compliance and continuous improvement within the Organization.

Perform job functions consistent with the company’s mission and vision statements, and core values.

Perform other duties, roles and responsibilities analogous, related, similar, germane and/or limited to the above-mentioned.

Computer literate, preferably with working knowledge in using MS Office Suite (Word, Excel, PPT, etc.)

Significant organizational skills

Strong analytical and problem-solving skills

Excellent attention to detail and quality-focused.

Ability to manage own work requirements.

Ability to construct letters that conform to prescribed style and format.