EDI Database Programmer

The EDI Database Programmer position in the Analytics and Reporting Department is responsible for managing data error reconciliation and submission to the New York State Department of Health (NYSDOH), Centers for Medicare and Medicaid Services (CMS), and other regulatory entities, as required. This role includes troubleshooting Electronic Data Interchange (EDI) mapping issues and encountering data reporting errors; monitoring encounter data quality reports; and ensuring adherence to EDI standards. Additional responsibilities include writing complex SQL queries and stored procedures; developing and maintaining SQL Server Integration Services (SSIS) jobs for EDI file submissions; troubleshooting EDI error records; and maintaining comprehensive EDI documentation, including process flows. The role also involves collaborating cross-functionally to identify and resolve EDI issues, as well as preparing test data, conditions, and expected outcomes to validate new EDI updates and logic related to Social Care Network claims, Health Recovery Plan (HRP) transitions, retroactive rate changes, State Directed Payments, and risk adjustment encounter submissions.

The successful candidate will possess strong SQL programming and EDI analytical skills, excellent communication abilities, and healthcare experience, including knowledge of membership, provider, and claims data.

Scope of Role & Responsibilities

• Monitor encounter fallouts and reconcile and re-submit fallout encounter data files to NYSDOH OSDS and CMS.
• Collaborate with vendors/end users on correcting EDI error transactions and resubmissions to NYSDOH and CMS for Retro Rate adjustments, State Directed payments and Risk adjustments.
• Automate manual processes for encounter data error re-submissions.
• Support compliance and regulatory for any inquiry on encounter data processes.
• Support MMCOR reporting and other regulatory reporting.
• Create KPI reports on encounter reconciliation reporting.
• Create SQL stored procedures, SSIS packages, flow diagrams and document the process for Encounter Data Reporting.
• Develop and test EDI mapping for encounter submissions.
• Troubleshoot EDI errors and keep track of all the resubmissions.

Do you have experience in XML?, Do you have a Bachelor’s degree?, * Minimum of 7 years of experience in SQL Server database development, including stored procedures, functions, views, SSIS, SSRS, X12 EDI mapping and development, and troubleshooting EDI errors.

• Bachelor’s degree required in Information Systems, Computer Science, or Database Management
• Minimum of 4 years of experience working with complex healthcare data, including claims, enrollment, and provider data.
• Strong knowledge of EDI X12 standards, particularly transactions 837, 834, 277CA, and 999.
• Prior experience submitting encounters to NYSDOH is preferred but not required.
• Experience with BI reporting tools such as BusinessObjects, Tableau, or Power BI.Working knowledge of Visual Studio, NET development, XML, BizTalk, and Health Rules Payor.

Professional Competencies

• Integrity and Trust
• Collaboration and Time management skills
• Functional/Technical skills
• Written/Oral Communication
• Teamwork
• Excellent analytical and problem-solving skills.
• Ability to work effectively in a team environment and adapt quickly to changing projects and priorities.