Role Overview
We are looking for experienced EDI Healthcare Analysts with strong expertise in encounter data processing, EDI submission, reconciliation testing, and member enrollment workflows for a healthcare payer.
What You Will Do
The main day-to-day responsibilities include encounter data processing, EDI submission, and reconciliation testing for a healthcare payer, as well as member enrollment workflows.
Why It Might Be a Fit
This role requires strong technical and domain expertise in EDI, healthcare payer domain knowledge, and experience with Edifecs or equivalent EDI validation tooling.
Requirements
- Experience in encounter data processing, EDI submission, and reconciliation testing for a healthcare payer
- X12 EDI knowledge: 837P, 837I, 837D (Professional, Institutional, Dental)
- Facets — REQUIRED: claims module familiarity (encounters are derived from Facets claims data); Facets-to-encounter data validation
- SQL for encounter data validation (claim header, detail, member eligibility cross-checks)
- TOSCA or Robot Framework test automation
- Healthcare payer domain knowledge including CMS encounter submission rules and state-specific companion guides
- Facets — REQUIRED: membership/enrollment module testing, subscriber/member configuration, and 834-to-Facets data flow validation
- X12 EDI: 834 (Benefit Enrollment & Maintenance) — full transaction expertise
- Experience with member add/change/term, dependent handling, dual-enrollment scenarios
- Knowledge of retroactive adjustments and deeming logic (Medicaid/MMP/Dual)
- 820 (Premium Payment) validation linkage
- Member eligibility cross-validation (270/271 correlation)
- Enrollment reconciliation: source system vs. downstream (enrollment DB ↔ claims ↔ eligibility)
- SQL for member-level data comparisons (effective dates, plan codes, LOB flags)
- Experience with TOSCA or similar automation tools
- LOB knowledge: Medicaid, Medicare Advantage, Duals/MMP, TRICARE, Marketplace
Benefits
- W2 employment
- Hourly rate of $40
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