The EDI Consultant is responsible for submitting medical claims, monitoring electronic documents, and resolving submission errors with clearinghouses. They also facilitate the onboarding of new clients and ensure data integrity across all EDI interfaces.
Salary: PHP 25,000 - PHP 35,000/ month
Job Description:
Submitting medical claims to the proper clearinghouse for the insurance payers to review and make the proper decision and payments.
Processing & monitoring of all claim reports & electronic documents. (Electronic and Paper Claim Transactions).
Logging in and tracking all submission and rejection information.
Responsible for obtaining edit reports and repair claims for re submission, test, and ensure repairs are made in a timely manner. Make sure that the claim was sent to the proper clearinghouse.
Backup the EDI claim submission and logging of information.
Keeps an update of Policy, Regulations and Payer/Clearinghouse changes.
Coordinating & testing all Electronic Data Interchange (EDI) implementations with new EDI partners & current clearinghouse.
Coordinate and work with clearing houses or trading partners to resolve EDI issues such as rejection and submission errors. Collaborate with payers, clearinghouses and/or trading partners to successfully maintain the EDI processes.
Test, implement and document all processes required by the new accounts or new billing software.
Reviews, analyzes and coordinates implementation for service modifications by EDI ( new payer ID, claim edits)
Monitors daily EDI performance, analyzes complex datasets, and troubleshoots issues and resolve them in a timely manner.
Facilitates the successful on-boarding of new Clients EDI accounts.
Assure interfaces (ECPP, QRSP, and HPNA) are performing as designed.
Assure data integrity (correct files/batches are uploaded)
Manage the resolution process as needed (Coordination with Team, Leaders, account Manager)
Escalate EDI issues to Manager/ Credentialing if unable to resolve in a timely manner.
Manage Send/Receive Files, Work Rejected claim (daily).
Random Claim Status inquiry.
Claim File Reconciliation (batch received by charges and batch submitted by EDI)
Analyze Rejection and detection of error patterns that need correction on the billing end.
Minimum Qualifications:
At least 2 years of experience in Healthcare EDI, Medical Billing, or Claims Processing
Knowledge of EDI processes, claim submissions, clearinghouses, and rejection management
Familiar with healthcare insurance payers, claim edits, and reimbursement processes
Experience using EHR/EMR systems and billing software is preferred
Strong analytical, problem-solving, and organizational skills
Excellent communication and coordination skills
Detail-oriented and able to work in a fast-paced environment
Open to consultancy contract minimum of 6 months
Perks and Benefits:
Maternity & Paternity Leave
Government Contribution (SSS, Pag-ibig, Philhealth)
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