EDI Expert (Healthcare Claims Processing)

Position Title

EDI Expert – Healthcare Claims Processing - (CTH – No Sponsorhip)

Location

Indianapolis, IN

Work Schedule

Hybrid – 3 Days Onsite / 2 Days Remote

📌 Selected resource will be required to work onsite 3 days per week and 2 days remote. Please confirm the candidate understands and accepts this requirement.

Interview Process

·         Initial Technical Interview: Microsoft Teams

·         Final Interview: Teams or In-Person (Manager''s Discretion)

Duration

Long-Term Contract

Position Overview

The Indiana Department of Health (IDOH) is seeking an experienced EDI Expert to support, maintain, and enhance its health insurance claims processing system, ACAPS.

The EDI Expert will be responsible for managing the complete lifecycle of healthcare claims processing, including receipt of claims from healthcare providers, loading and validation of EDI transactions, claims adjudication, and generation of outbound adjudication responses.

This individual will serve as a Subject Matter Expert (SME) on healthcare EDI transactions and claims processing while supporting the modernization of the ACAPS application as it is rewritten in .NET.

The selected candidate will work closely with project managers, software developers, business analysts, functional teams, healthcare providers, and external trading partners to ensure seamless EDI operations and compliance with healthcare standards.

Key Responsibilities

EDI & Claims Processing Support

·         Support and maintain healthcare claims processing operations within the ACAPS system.

·         Manage the lifecycle of inbound and outbound EDI claim transactions.

·         Ensure accurate processing of healthcare claims and adjudication transactions.

·         Monitor and troubleshoot EDI file transmission and processing issues.

Documentation & Process Analysis

·         Review and update all claims processing and EDI-related documentation.

·         Identify undocumented business processes and create detailed documentation.

·         Develop technical specifications based on business and system requirements.

Subject Matter Expertise

·         Serve as the EDI and claims processing SME during the modernization of the ACAPS application.

·         Collaborate with developers during the .NET redevelopment effort.

·         Provide guidance on healthcare EDI standards and best practices.

Business & Stakeholder Collaboration

·         Act as liaison between technical teams and Children’s Health Services program stakeholders.

·         Work with business users to gather and clarify requirements.

·         Ensure alignment with agency standards, healthcare regulations, and federal/state policies.

Testing & Quality Assurance

·         Participate in system testing activities.

·         Validate new functionality and enhancements.

·         Support user acceptance testing (UAT) efforts.

Provider & Trading Partner Support

·         Provide helpdesk-level support for EDI claim transactions.

·         Assist healthcare providers with EDI transaction issues.

·         Support onboarding of new providers and clearinghouses.

·         Resolve EDI data exchange and transmission conflicts.

Required Qualifications

·         Bachelor’s Degree in Computer Science, Information Technology, or related field

·         Strong database knowledge

·         Experience working with healthcare EDI transactions

·         Understanding of EDI file formats including:

o    835 Healthcare Claim Payment/Advice

o    837 Healthcare Claim Transactions

o    210 Transportation Invoice (if applicable)

·         Knowledge of HIPAA regulations and compliance requirements

·         Strong troubleshooting and problem-solving skills

·         Excellent verbal and written communication skills

·         Ability to work independently with minimal supervision

Highly Desired Qualifications

·         Healthcare industry experience

·         Experience supporting healthcare claims processing systems

·         Knowledge of IBM WebSphere Transformation Extender (WTX)

·         Strong SQL and database development experience

·         Experience working with clearinghouses and healthcare providers

·         Experience supporting EDI integrations and trading partner onboarding

Technical Environment

·         EDI Transactions (835, 837, 210)

·         Healthcare Claims Processing

·         HIPAA Compliance

·         SQL Databases

·         IBM WebSphere (WTX)

·         .NET Applications

·         Data Exchange & Integration

·         Trading Partner Management