Job Description
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 Originally posted on Hi
