Healthcare EDI Transactions Expert

Help resolve the transaction failures that delay claims and payments. Your expertise will connect detailed EDI analysis with complaint investigations, regulatory guidance, and corrective actions that help providers and health plans exchange information reliably. Location: Remote About Radiant and position Radiant Infotech is a Maryland-based small business delivering software development, data management, cloud, and cybersecurity services to federal agencies. This position supports Centers for Medicare and Medicaid on HIPAA Administrative Simplification, with a focus on complaint review, transaction testing, and technical assistance. You will work with enforcement analysts, technical teams, and healthcare stakeholders to identify compliance gaps and develop clear, practical recommendations. What You’ll Do Investigate complaints. Triage HIPAA Administrative Simplification complaints, review transaction records and responses from complainants and entities under review, identify potential noncompliance, and prioritize follow-up. Prepare findings and recommendations. Connect the evidence to applicable requirements and provide clear, substantiated findings and recommended next steps to enforcement analysts. Resolve EDI problems. Troubleshoot validation failures, formatting errors, data-mapping issues, and transaction-processing problems. Reproduce issues, test solutions, and explain outcomes to technical and business stakeholders. Guide compliance and corrective actions. Clarify transaction standards, implementation specifications, code sets, and applicable operating rules. Recommend practical steps to address compliance gaps and reduce recurring issues. Develop useful documentation. Write and maintain SOPs, technical guidance, and reference materials for transaction handling, complaint review, compliance workflows, and corrective action processes. Monitor changing requirements. Track regulatory developments and industry guidance, assess their implications, and update procedures and recommendations as needed. Required Qualifications Relevant experience and education. At least five years of experience in healthcare EDI, HIPAA compliance, or a related healthcare compliance field, plus a relevant bachelor’s degree or equivalent work experience. Applied HIPAA expertise. Strong knowledge of HIPAA Administrative Simplification transaction standards, code sets, and applicable operating rules under 45 CFR Part 162, with knowledge of relevant requirements in Parts 160 and 164. Hands-on X12 experience. Ability to analyze, validate, and troubleshoot Version 5010 transactions: 837 (professional, institutional, and dental claims), 270/271 (eligibility and benefits), 835 (payment and remittance advice), 276/277 (claim status), and 278 (prior authorization and referrals). Knowledge of related standards. Experience with claims attachment workflows and the use of ICD-10, CPT, and HCPCS code sets, along with working knowledge of NCPDP standards for retail pharmacy claims and eligibility. Testing and troubleshooting skills. Experience testing healthcare transactions and interfaces with claims adjudication systems, such as Medicaid Management Information Systems (MMIS), using Edifecs, TIBCO, or comparable tools to investigate and resolve EDI issues. Clear analysis and communication. Ability to evaluate evidence, produce precise findings and procedures, and explain complex technical and regulatory requirements to analysts, developers, and healthcare stakeholders. Preferred Qualifications Health plan experience implementing healthcare transactions and operating rules, including coding, data mapping, and technical assistance. Participation in or exposure to industry organizations such as X12N, CAQH CORE, and WEDI. Experience developing healthcare transaction guidance and supporting compliance investigations or corrective action planning. What We Offer A 401(k) plan with employer contributions. Professional development opportunities in a collaborative work environment. Radiant is an equal opportunity employer. We welcome qualified applicants from all backgrounds. Reasonable accommodations are available for applicants with disabilities during the application and interview process. #J-18808-Ljbffr