Job Description:
Qualifacts is a leading provider of behavioral health software and SaaS solutions for clinical productivity, compliance and state reporting, billing, and business intelligence. Its mission is to be an innovative and trusted technology and end-to-end solutions partner, enabling exceptional outcomes for its customers and those they serve. Qualifacts’ comprehensive portfolio, including the CareLogic®, Credible™, and InSync® platforms, spans and serves the entire behavioral health, rehabilitative, and human services market supporting non-profit Certified Community Behavioral Health Clinics (CCBHC) as well as for-profit large enterprise and small business providers. Qualifacts has a loyal customer base, with more than 2,500 customers representing 75,000 providers serving more than 6 million patients. Qualifacts was recognized in the 2022 and 2023 Best in KLAS: Software and Services report as having the top ranked Behavioral Health EHR solutions.
This is an onsite position, 5 days/week, in the Vadodara office.
Shift: -NIGHT/US SHIFT. 6:30pm-3:30am IST.
Remote applicants will not be considered.
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Prepare, submit, monitor, and maintain EDI enrollment requests for electronic transactions, including:
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Electronic Claims (837)
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Electronic Remittance Advice (ERA/835)
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Electronic Funds Transfer (EFT)
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Claim Status transactions (276/277), where applicable
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Eligibility transactions (270/271), where applicable
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Complete payer-specific electronic enrollment applications through payer portals, clearinghouses, and paper enrollment processes, as required.
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Coordinate EDI enrollments with clearinghouses and insurance payers to establish electronic connectivity for assigned providers and client groups.
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Validate provider demographic information, National Provider Identifier (NPI), Tax Identification Number (TIN), billing information, and banking details before submission to ensure enrollment accuracy.
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Track enrollment status, payer responses, effective dates, approvals, and activation milestones through completion.
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Perform timely follow-up with insurance payers and clearinghouses to obtain enrollment status, resolve deficiencies, and expedite approvals.
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Investigate and resolve rejected, delayed, or incomplete EDI enrollment requests.
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Escalate aging enrollments, payer delays, or connectivity issues that may impact claims submission or payment processing.
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Maintain consistent communication with internal stakeholders regarding enrollment progress, risks, and expected completion timelines.
Documentation & Quality
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Maintain accurate documentation within enrollment systems, work queues, trackers, CMD records, and document repositories.
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Document payer communications, enrollment approvals, rejection reasons, and corrective actions in accordance with RCMS documentation standards.
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Ensure all enrollment records are complete, current, and audit-ready.
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Safeguard sensitive provider and banking information while adhering to HIPAA and organizational security requirements.
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Partner with Credentialing, Billing, AR, Payment Posting, Client Success, Implementations, and U.S.-based teams to support provider onboarding and revenue cycle readiness.
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Coordinate with internal departments to resolve enrollment dependencies affecting electronic claims submission or payment processing.
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Support new client implementations, provider onboarding, and organizational growth initiatives by ensuring timely EDI setup.
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Identify process improvement opportunities to reduce enrollment turnaround times, improve first-pass approval rates, and standardize EDI workflows.
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Assist in training team members and sharing payer-specific EDI enrollment knowledge and best practices.
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Strong understanding of U.S. healthcare EDI enrollment processes and payer electronic connectivity requirements.
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Working knowledge of HIPAA electronic transaction standards, including:
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837 Electronic Claims
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835 Electronic Remittance Advice (ERA)
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Electronic Funds Transfer (EFT)
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270/271 Eligibility Transactions (preferred)
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276/277 Claim Status Transactions (preferred)
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Experience working with commercial, Medicare, Medicaid, and managed care payer electronic enrollment processes.
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Familiarity with major clearinghouses and payer portals.
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Strong analytical and troubleshooting skills to resolve EDI enrollment issues efficiently.
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Excellent organizational skills with the ability to manage multiple enrollments and competing priorities.
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Strong written and verbal communication skills.
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High attention to detail and commitment to documentation accuracy.
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Proficiency with Microsoft Excel, Word, Outlook, enrollment tracking systems, payer portals, and clearinghouse platforms.
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EDI enrollment requests are submitted accurately and within established internal and payer SLA timelines.
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High first-pass acceptance rate with minimal enrollment rework or resubmissions.
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EFT and ERA enrollments are activated promptly, minimizing payment delays.
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Enrollment trackers, CMD records, and documentation repositories maintain a minimum 98% quality standard.
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Payer and clearinghouse follow-ups are completed within established service standards and documented appropriately.
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Aging enrollments are proactively managed and escalated with clear action plans.
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Audit results demonstrate complete documentation, strong process adherence, and minimal corrective actions.
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Electronic connectivity issues are resolved efficiently with minimal disruption to claims processing and reimbursement.
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Minimum 2 years of experience in Healthcare Revenue Cycle Management with direct responsibility for EDI Enrollment.
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Demonstrated experience managing EFT, ERA, and electronic claims enrollments.
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Experience working with commercial, Medicare, and Medicaid payer electronic enrollment processes.
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Familiarity with clearinghouse platforms and payer portals.
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Working knowledge of HIPAA electronic transaction standards and healthcare EDI workflows.
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Experience using enrollment management systems and Microsoft Office applications.
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Bachelor's degree or equivalent healthcare operations experience preferred.
Qualifacts is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
