Gokulakrishnan V

Set up and maintain EDI connections with partners (vendors, customers, carriers).

Monitor EDI transactions (inbound/outbound), ensure timely and accurate data exchange.

Troubleshoot and resolve EDI errors/failures (e.g., 997 rejections, mapping issues).

Develop and maintain maps for document types (e.g., 810, 850, 856, 997, 837, etc.).

Test and implement new trading partners.

Work with EDI standards (ANSI X12, EDIFACT) and communication protocols (AS2, FTP, SFTP, VAN).

Generate reports on EDI transactions and compliance.

• Apply policy rules and guidelines to determine payable amount, denials, or adjustments.
• Calculate co-payments, deductibles, coinsurance, and maximum benefit limits.
• Ensure accurate CPT, ICD-10, HCPCS code usage and validate medical necessity.
• Send recovery notices to providers or members with repayment details.
• Initiate offsets (adjustments in future payments) or refund requests.
• Set up payment plans for large recoveries if needed.
• Recovering overpaid amounts from healthcare providers.
• Recovering overpayments to patients/members.