Medicare and EDI Senior Specialist

The Medicare and EDI Senior Specialist will serve as Pie's internal subject matter expert for both Medicare Secondary Payer (MSP) compliance and assist the Senior EDI Specialist with Electronic Data Interchange (EDI) reporting requirements. This role is critical  to ensure compliance with federal Section 111 Medicare, Medicaid, and SCHIP Extension Act (MMSEA) reporting mandates and state-specific EDI requirements across all jurisdictions. The specialist will work closely with claims, legal, and compliance teams to mitigate regulatory risk, avoid costly penalties, and maintain operational efficiency as our claim volume continues to grow.

How You'll Do It

Medicare Secondary Payer (MSP) Compliance

• Ensure compliance with Medicare Secondary Payer (MSP) regulations and guidelines related to workers' compensation and commercial auto claims by staying up-to-date with Medicare regulations and implementing them into the claims handling process
• Communicate and coordinate with the Centers for Medicare and Medicaid Services (CMS), Medicare Administrative Contractors (MAC) and Section 111 to report and resolve Medicare-related issues and inquiries
• Review workers' compensation and commercial auto claims to identify potential Medicare beneficiaries and assess the need for Medicare reporting and compliance by analyzing claim details, medical records, and treatment plans to assist the claims team in determining primary payer responsibility
• Generate and submit required reports and documentation to Medicare and other relevant authorities, including reporting claims information, tracking payments made, and ensuring accurate and timely reporting of any changes or updates to claim status
• Ensure data accuracy and completeness by coordinating across claims, legal, and compliance functions
• Resolve transmission errors and address data inconsistencies flagged by CMS
• Track ORM and TPOC reporting status to ensure all qualifying claims are reported
• Maintain internal logs and audit trails of all reports, submissions, and CMS acknowledgments
• Reconcile accepted vs. rejected claim records and resolve discrepancies
• Stay current on CMS updates, guidance, and policy memos related to Section 111 reporting

EDI Error Resolution & Process Management

• Management and resolution of  pending EDI errors across all jurisdictions
• Analysis of the root cause of errors, re-submission, and stakeholder coordination for each error
• Collaboration with internal teams and claims system vendor for system enhancements

Risk Management & Penalty Mitigation

• Investigation of root causes of penalties and coordinate responses with internal teams
• Proactively identify  compliance risks to prevent financial exposure
• Assist in the management of portal systems for multiple states (e.g., NY Ecase, PA WCAIS, MD CompHub)

Training & Process Improvement

• Conduct monthly EDI training sessions for team members on evolving requirements
• Assist in the creation of comprehensive SOPs for Medicare reporting and EDI practices
• Assist in providing daily support to field adjusters on compliance-related queries
• Attend educational conferences to stay current on compliance standards

Quality Assurance & Auditing

• Assist with quarterly audits to ensure data integrity and regulatory compliance
• Assist with quality control over vendor submissions and data integrity
• Assist with management of claims compliance inbox and routine filing requirements
• Assist with filing of jurisdiction-specific forms (AR Form M monthly, ID IC-36 quarterly)

The Right Stuff

Required Experience

• 8-12 years of experience in workers' compensation compliance, Medicare reporting, or EDI processes
• Deep expertise in Medicare Secondary Payer (MSP) regulations and MMSEA Section 111 requirements
• Advanced knowledge of EDI standards, IAIABC formats, and state-specific reporting requirements
• Experience with CMS systems, particularly COBSW (Coordination of Benefits Secure Website)
• Strong understanding of workers' compensation regulations across multiple jurisdictions

Technical & Regulatory Expertise

• Expert-level knowledge of Medicare reporting requirements and CMS penalty structures
• Advanced proficiency with EDI platforms, data transmission systems, and error resolution processes
• Experience with Trading Partner Agreements (TPAs) and multi-jurisdictional filing requirements
• Understanding of IAIABC Release 3.1 standards and transition requirements
• Knowledge of state-specific portal systems and compliance requirements
• Experience with data analysis, reconciliation, and quality assurance processes

The use of AI in Application Review: To support a fair, efficient, and consistent hiring process, we use AI-powered tools to assist in the initial screening of applications. These tools help us identify qualifications and prior work experiences that align with the requirements of the role. All AI-reviewed applications are still subject to human oversight and decision-making at multiple stages of the process. By submitting your application, you acknowledge and consent to Pie utilizing these AI technologies to assist in our evaluation process.