We are seeking a skilled EDI Consultant with specialized experience in healthcare claim transactions to support our Data Integration (DI) Review & Validation efforts. The ideal candidate will have a strong background in 837P professional claim formats and CMS-1500 form mappings, with the ability to assess and validate system logic against payer-specific requirements. Key Responsibilities: Conduct detailed reviews of 837P (Professional) EDI transactions to ensure data integrity and format accuracy. Validate mappings to CMS-1500 claim forms , ensuring alignment between electronic and paper-based formats. Review and confirm correct population of provider fields (e.g., Rendering NPI, Supervising NPI ) at both line-item and claim levels . Identify, document, and communicate any gaps, mismatches, or inconsistencies between system-generated data and payer requirements. Collaborate with cross-functional teams (EDI developers, business analysts, QA) to provide feedback and recommend corrections. Participate in user acceptance testing (UAT) and post-deployment validation to ensure implementation success. Stay updated on HIPAA EDI standards and payer-specific guidelines related to 837P/CMS-1500 submissions. Required Qualifications: Proven experience working with 837P transactions and CMS-1500 claim formats. Strong understanding of HIPAA EDI standards , claim data elements, and provider field logic. Hands-on experience with claim validation tools, EDI mapping, and system configuration review. Familiarity with payer-specific submission requirements and business rules. Ability to analyze large data sets and identify discrepancies or issues efficiently. Excellent documentation, communication, and collaboration skills. Preferred Qualifications: Experience with clearinghouses or payers. Familiarity with 837I or other transaction sets (e.g., 835, 999, 277CA). Prior work with EHR/EMR or billing system integrations. #J-18808-Ljbffr Calpion/Plutus Health
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