Application Developer-Electronic Data Interchange (EDI)

Expertise Healthcare Industry Knowledge : Strong understanding of utilization management, prior authorization workflows, and clinical coding systems including ICD, CPT, and HCPCS. Payer-Provider Dynamics : Familiarity with healthcare regulatory requirements and payer-provider interactions.EDI & HIPAA Compliance EDI 278 Mastery : Deep expertise in the structure, segments, and loops of the EDI 278 transaction set used for healthcare service review requests. HIPAA Standards : Solid grasp of HIPAA transaction compliance and data privacy regulations.Data Handling & Interpretation Unstructured Data Extraction : Skilled in extracting relevant information from scanned faxes, PDFs, and other unstructured formats. Clinical Insight : Ability to interpret clinical documentation, patient demographics, provider credentials, and requested services.Mapping & Transformation EDI Field Mapping : Experience in mapping extracted data to EDI 278 fields and standardized codes. Automation Tools : Proficiency in scripting (e.g., Python) and ETL platforms for data transformation and integration.Technical Proficiency Integration Platforms : Familiarity with EDI software, healthcare integration engines, and custom automation tools. OCR & File Formats : Understanding of OCR technologies and file formats like PDF and TIFF for digitizing faxed content.Quality Assurance Validation & Testing : Ability to review and test EDI files for accuracy, completeness, and compliance before submission. Troubleshooting : Skilled in resolving mapping errors and data inconsistencies.Collaboration & Documentation Cross-Functional Communication : Effective communicator with clinical, IT, and operations teams to clarify requirements and resolve ambiguities. Process Documentation : Capable of documenting mapping rules, workflows, and audit trails for training and compliance.Nice to Have FHIR Knowledge : Exposure to HL7 FHIR standards and their application in healthcare data exchange. Other EDI Transactions : Familiarity with additional HIPAA EDI files such as 837 (claims), 835 (remittance), 276 / 277 (claim status), and 270 / 271 (eligibility).