EDI Developer

About the role

This role is responsible for designing, supporting, and maintaining a large scale healthcare billing and eligibility platform that processes Medicaid and commercial insurance transactions across multiple states. The developer will own end-to-end billing workflows—including eligibility, claim submission, remittance processing, escrow and recoupment logic, and corrections—ensuring claims are accurate, compliant, and paid correctly. The developer will work heavily in backend integration services, SQL Server stored procedures, and batch processing systems, troubleshooting complex production issues, implementing payer- and state-specific business rules, and performing data corrections when needed. This role requires close collaboration with billing operations, data teams, and compliance stakeholders to translate policy and reimbursement rules into reliable system behavior.

Responsibilities

• Design, support, and maintain a large scale healthcare billing and eligibility platform that processes Medicaid and commercial insurance transactions across multiple states.
• Own end-to-end billing workflows including eligibility, claim submission, remittance processing, escrow and recoupment logic, and corrections, ensuring claims are accurate, compliant, and paid correctly.
• Work heavily in backend integration services, SQL Server stored procedures, and batch processing systems, troubleshooting complex production issues, implementing payer- and state-specific business rules, and performing data corrections when needed.
• Collaborate with billing operations, data teams, and compliance stakeholders to translate policy and reimbursement rules into reliable system behavior.
• Keep mission critical billing processes running, resolve production issues quickly and safely, prevent duplicate or incorrect claims, and continuously improve the stability, performance, and correctness of a business-critical system.

Required Skills

• Deep experience with HIPAA X12 transactions: 270/271 (Eligibility), 276/277 (Claim Status), 837P/I (Claims), 835 (Remittance), 999/TA1 acknowledgements
• Strong understanding of Medicaid and commercial insurance billing workflows, including Primary vs secondary claims, Escrow and recoupment logic, voids, corrections, rebills, sweeps, denials, and adjustments
• Understanding of Healthcare revenue & claims life cycle including, escrow, takebacks, overpayments, rate corrections, voids, corrections, rebills, sweeps, and reprocessing
• Advanced SQL Server skills including writing, debugging, and optimizing complex stored procedures, diagnosing stuck records, data corrections, backfills, and one-time cleanup scripts in production
• Experience maintaining batch-oriented and transaction-oriented processing systems
• Design and support SFTP-based inbound/outbound integrations for large flat files (837/835, eligibility feeds, daily ETLs)
• Build and maintain high-volume, batch-oriented, file-based processing workflows
• Implement resilient import pipelines with error handling, retry logic, alerting, and recovery mechanisms
• Experience operating production systems in AWS
• Proven ability to triage production issues quickly using logs, data analysis, and job history
• Identify root causes across application code, stored procedures, and data and execute fixes under production pressure
• Respond to recurring system alerts and eliminate root causes
• Diagnose job timing, retries, late files, partial runs
• Implement and maintain complex validation/edit logic
• Translate policy changes into code and data changes
• Design and support configurable solutions to accommodate varying state rules
• Comfortable working with domain experts (billing, compliance, operations)
• Writes clear, auditable SQL and application logic
• Documents decisions and understands regulatory impact

Technical Skills

• .NET Development: C# development with .NET Core 6/8/10, .NET Framework 4.8, and ASP.NET Web Forms
• EDI/X12 processing using EdiFabric or equivalent
• X12 transaction pipelines (837, 835, eligibility, acknowledgments)
• Secure application development including PII/PHI handling (HIPAA) and role-based access
• Configuration-driven architecture separating code from environment, client, and state/agency rules
• SQL Server 2019+ Advanced TSQL (complex queries, data modification, performance optimization)
• SSIS package maintenance and tuning
• Stored procedures, views, and database security
• Data analysis across highly configurable schemas
• Database deployment and release scripting
• ORM & Data Access: Entity Framework LINQ query composition, DbContext lifecycle and performance management
• Application quality & performance tuning
• Code refactoring for maintainability and scalability
• Unit testing for new and existing functionality
• Source Control & DevOps: Git (branching strategies, pull requests, code reviews), Azure DevOps (pipelines, work items, repositories)
• Configuration & Deployment: Environment-aware development and deployment patterns
• File-based and database-driven configuration management