EDI Claims Implementation Specialist

ZipStaff • Chapel Hill, NC

6h • Remote

About The Position

ZipStaff is seeking an EDI Claims Implementation Specialist for a contract assignment supporting a system migration for a Massachusetts Medicaid client at a major managed care organization. The role bridges inbound claims, adjudication-system impacts, and downstream encounter reporting as the client transitions from one claims platform to another. It is a hands-on healthcare claims implementation role, rather than a general EDI developer or purely outbound reporting position.

The specialist will support inbound, pre-adjudication 837 claim ingestion from providers, including intake, mapping, validation, and routing into the claims platform. The role also supports post-adjudication 837 encounter reporting, including extraction, mapping, validation, submission, acknowledgments, and reconciliation. The specialist will assess impacts to adjudication, eligibility, and accumulator processing; validate claims and encounter data across platforms; drive defect resolution through cutover; and partner with functional and technical teams to keep the migration on track.

Requirements

• At least 5 years of hands-on EDI claims and implementation experience in healthcare insurance.
• Strong inbound claims experience covering 837 claim ingestion, intake, mapping, validation, and routing; inbound experience is preferred over outbound experience.
• Post-adjudication experience with 837 encounter reporting, including extraction, mapping, submission, acknowledgments, and reconciliation.
• Recent experience within the last 4 years in healthcare insurance claims, eligibility, and accumulators.
• Proven experience supporting system migrations or implementations in which claims processing and encounter reporting moved between platforms.
• Must be legally authorized to work in the United States without sponsorship now or in the future.

Nice To Haves

• MassHealth or Medicaid experience.
• Familiarity with MassHealth 837 encounter reporting requirements.
• Experience with both inbound and outbound claims.
• Behavioral health or managed care background.

Responsibilities

• Support migration of a Massachusetts Medicaid client from one claims system to another.
• Own inbound, pre-adjudication 837 claim ingestion from providers, including EDI intake, mapping, validation, and routing into the claims platform.
• Support post-adjudication 837 encounter reporting, including extraction, mapping, validation, submission, acknowledgments, and reconciliation.
• Assess and address impacts to adjudication, eligibility, and accumulator processing during the transition.
• Validate claims and encounter data across platforms.
• Drive defect resolution through cutover.
• Partner with functional and technical teams to keep the migration on track.

Benefits

• Health insurance.
• Dental insurance.
• Vision insurance.
• 401(k).
• 401(k) matching.
• Paid time off.
• Referral program.

What This Job Offers

• Education Level: No Education Listed