EDI Consultant, Healthcare

• Submit medical claims to the proper clearinghouse for insurance payer review and payment decisions
• Process and monitor claim reports and electronic and paper claim transactions
• Log and track submission and rejection information
• Obtain edit reports and repair claims for resubmission; test and ensure timely repairs
• Verify claims are sent to the proper clearinghouse
• Back up EDI claim submissions and related information
• Keep updated on policies, regulations, and payer/clearinghouse changes
• Coordinate and test EDI implementations with new EDI partners and current clearinghouses
• Resolve EDI issues such as rejection and submission errors with clearinghouses and trading partners
• Collaborate with payers, clearinghouses, and trading partners to maintain EDI processes
• Test, implement, and document processes for new accounts or billing software
• Review and coordinate service modifications, including new payer IDs and claim edits
• Monitor daily EDI performance, analyze complex datasets, troubleshoot issues, and resolve them timely
• Facilitate onboarding of new client EDI accounts
• Ensure ECPP, QRSP, and HPNA interfaces perform as designed
• Ensure data integrity for uploaded files and batches
• Manage resolution processes and coordinate with teams, leaders, and account managers
• Escalate unresolved EDI issues to Manager/Credentialing
• Manage send/receive files and work rejected claims daily
• Perform random claim status inquiries
• Reconcile claim files between received charges and EDI submissions
• Analyze rejections and identify error patterns requiring billing corrections

• 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

• Maternity & Paternity Leave
• Government Contribution (SSS, Pag-ibig, Philhealth)
• 13th Month Pay
• Paid Holidays
• Bereavement Leave
• Paid Vacation Leave
• Paid Sick Leave
• Work from Home
• Equipment/ company computer is provided
• Night shift differential pay
• Php 1,000 De Minimis
• Php 1,000 monthly bonus upon regularization
• HMO upon regularization