EDI Encounter Specialist

Doctors Healthcare Plans•Coral Gables, FL

About The Position

The EDI Encounter Specialist is responsible for the administration, monitoring, validation, and support of healthcare encounter data submitted to state (AHCA) and CMS, as well as those received from clearinghouses and business partners. This position ensures encounter data is complete, accurate, compliant, and submitted within required regulatory timeframes. The specialist works closely with Claims, IT, Compliance, Finance, Vendor Management, and external vendors to identify, research, and resolve encounter submission issues while maintaining compliance with CMS, AHCA, HIPAA, and ANSI X12 standards.

Requirements

Bachelor's degree in Information Systems, Healthcare Administration, Computer Science, Business, or equivalent experience.
3–5 years of healthcare EDI or encounter management experience.
Experience working with healthcare claims and encounter data.
Knowledge of HIPAA X12 transaction standards.
Strong analytical and problem-solving skills.
Excellent written and verbal communication skills.

Nice To Haves

Experience submitting encounters to CMS, AHCA, or state Medicaid agencies.
Experience with Edifecs, Health Suite.
Knowledge of healthcare regulatory requirements.

Responsibilities

Monitor daily encounter file processing and submission activities.
Validate encounter data prior to submission to ensure completeness and accuracy.
Research and resolve rejected encounters from AHCA, CMS, or clearinghouses.
Analyze encounter acceptance and rejection reports to identify trends and root causes.
Coordinate resubmission of corrected encounter records.
Perform reconciliation between claims adjudication systems and submitted encounter.
Work with business users and IT to resolve data quality issues.
Ensure encounter submissions comply with CMS, AHCA, HIPAA, and organizational.
Maintain submission schedules and regulatory deadlines.
Assist with implementation and testing of encounter-related system enhancements.
Document business processes, procedures, and issue resolutions.
Support audits and regulatory requests related to encounter data.
Participate in production support and issue resolution activities.
Support and troubleshoot HIPAA transactions including: 837 Professional (837P), 837 Institutional (837I), 837 Dental (837D), 999 Functional Acknowledgments, TA1 Interchange Acknowledgments, 277CA Claim Acknowledgments, 835 Electronic Remittance Advice (preferred) and 275 Attachments (preferred).
Validate encounter records prior to submission.
Monitor encounter acceptance and rejection rates.
Research front-end and back-end validation errors.
Coordinate corrections with Claims, Configuration, and IT teams.
Perform monthly encounter reconciliation.
Support encounter attestation processes.
Track encounter inventory and aging.
Maintain encounter dashboards and operational metrics.
Analyze recurring rejection patterns and recommend corrective actions.
Participate in user acceptance testing (UAT) for encounter enhancements.
Monitor overnight encounter processing.
Review encounter acceptance and rejection reports.
Research failed submissions and coordinate corrections.
Execute SQL queries for reconciliation and validation.
Work with Claims and IT to resolve data issues.
Track encounter inventory and aging.
Update operational dashboards.
Participate in production support meetings.
Coordinate vendor and clearinghouse communications.
Prepare regulatory submission status reports.