Job Description

Position Summary / Scope of Responsibility

MedVanta is the nation's largest physician-owned and operated next generation management services organization (MSO). Our services are specifically designed for musculoskeletal (MSK) providers and go beyond that of a traditional MSO, empowering our clients with the precise infrastructure, data, technology, and administrative processes needed to thrive both today and tomorrow.

MedVanta has an employee centered culture that supports and promotes diversity and inclusion. Our encouraging and empowering management style makes MedVanta a great place to further grow your knowledge while building a team driven path to success.

The EDI Specialist is responsible for managing daily claim submission workflows to ensure claims are transmitted accurately and accepted by clearinghouses and payers in a timely manner. This role monitors electronic and paper claim submissions, resolves clearinghouse and payer front-end rejections, and ensures proper coordination of benefits for primary, secondary, and tertiary claims. The position works closely with billing, registration, coding, and authorization teams to correct claim errors, address rejection trends, and support efficient front-end revenue cycle operations.

Primary Responsibilities

The incumbent may be asked to perform job-related tasks other than those specifically stated in this description. The duties and responsibilities of the position are to be carried out in a manner that is consistent with the Mission, Core Values and Operating Principles of MedVanta.

• Manage daily claim submission workflows for electronic and paper claims, ensuring timely release based on payer requirements and internal posting/submission schedules.
• Submit and monitor primary (INS1), secondary (INS2), and tertiary (INS3) claims as appropriate, ensuring correct payer sequencing, COB indicators, and remaining balance logic.
• For INS2/INS3, confirm required supporting data is present prior to submission (e.g., primary/secondary EOB/ERA information, patient responsibility allocation, COB details, payer address/ID, and any required attachments)
• Support payer/clearinghouse setup tasks for electronic transactions (e.g., claim submission connectivity, payer IDs, routing rules).
• Coordinate EDI-related items such as submitter IDs, trading partner setup, and payer-specific requirements (as assigned).
• Assist with maintaining accurate provider/location configuration elements that impact claims (NPI, taxonomy, address, EIN/TIN, pay-to/bill-to, etc.).
• Prepare and submit paper claims when required (payer-specific or exception-based), including proper form/format, claim attachments, and documentation of submission date and method.
• Validate claim routing (payer ID/plan mapping) and ensure claims are directed to the correct payer channel (electronic vs paper) to prevent avoidable rejections and delays.
• Track submission confirmations and acceptance status; follow up on non-accepted/not-submitted claims and re-submit after correction per policy.
• Work EDI edits including (examples): invalid member ID, subscriber mismatch, DOB/gender mismatch, payer ID/plan mapping, missing NPI/taxonomy, invalid place of service, invalid/expired authorization, referring provider data errors, rendering/billing provider mismatches, duplicate submission flags, and formatting issues.
• Maintain and improve edit libraries, common rejection knowledge base, and standardized resolution steps.
• Identify repeat rejection patterns; recommend upstream fixes (registration training, PM build changes, mapping updates).
• Escalate suspected system build issues, payer processing errors, or recurring defects with supporting examples.
• Partner with front-end AR reps to prevent aging in “not accepted / not submitted” status.
• Communicate clearly with registration, authorizations, and coding teams on required corrections and deadline expectations.
• Participate in huddles and trend reviews; share top rejection drivers and recommendations.
• Track and report metrics (daily/weekly) such as rejection volume, top rejection reasons, acceptance rate, and turnaround time.
• Support projects such as new payer implementations, clearinghouse updates, PM upgrades, and workflow redesign.
• Performs all other duties as assigned.

Reporting Relationships

The EDI specialist reports directly to the designated department lead.

Required Education and Experience

• High school diploma or GED equivalent required.
• Bachelor’s degree in Business Administration, Healthcare Administration, or Electronic Data Management preferred.
• Electronic Data Interchange certification strongly preferred.
• Familiarity with EDI software and data management tools, or the ability to quickly learn and adapt to EDI platforms and processes.
• Strong understanding of claim basics: subscriber vs patient, provider types, NPI/taxonomy, POS, ICD-10/CPT/HCPCS, authorization/referrals, COB, payer IDs and routing.
• Ability to navigate a PM system, clearinghouse portal, payer websites, and workqueues efficiently.
• Experience with high-volume multi-site physician group billing.
• Familiarity with ANSI X12 concepts (837P/835/276-277) and clearinghouse tools (specific platform experience a plus).
• Experience with ModMed/mmPM, Trizetto, Waystar, Change Healthcare, Availity, or similar tools (as applicable).
• Proficiency with Microsoft Office suite of products, as well as proficiency with standard office software and applications.
• Outstanding time management skills and the ability to work effectively across multiple forms of communication and teams.
• Strong organizational skills with the ability to multi-task and be effectively productive with little given direction in the highly demanding environment of an enterprise operating as a management service organization.

Competencies / Required Skills and Abilities

• Strong interpersonal skills - ability to develop relationships and collaborate and influence in a centralized organization.
• Demonstrated ability to organize, prioritize, and manage multiple tasks in a dynamic environment with a proven track record of results.
• Strong interpersonal, oral, and written communication skills with excellent self-discipline and patience.
• Able to work independently.
• Exudes professionalism in presentation.
• Must be able to read, write, speak, understand, and communicate in the English language.

Physical Demands

• Must be able to sit for long periods of time and lift up to 25 pounds
• Must be able to use appropriate body mechanics techniques when performing desk duties.
• Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting, and sitting.
• Adequate hearing to perform duties in person and over telephone.
• Must be able to communicate clearly to individuals in person and over the telephone.
• Visual acuity adequate to perform job duties, including reading materials from printed sources and computer screens.

Benefits Include:

Medical, dental, and vision insurance | Flexible Spending Account (FSA) and Health Savings Account (HSA) options | 401(k) retirement plan with employer contributions | Paid time off and paid holidays | Employer-paid life insurance | Voluntary supplemental benefits including disability and additional coverage options | Employee Assistance Program (EAP)

Full-time employees are eligible for employer-paid life insurance. Part-time employees are eligible for 401(k) participation. Benefits eligibility and employer contribution levels may vary.