Position: EDI Healthcare Analyst (Claims / Encounters & Enrollment)
Location: Remote (US Only)
Employment Type: W2
Rate: $40/hr (No Benefits)
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.
Core Technical & Domain Requirements:
Encounter / Claims (EDI 837 Focus):
- Experience in encounter data processing, EDI submission, and reconciliation testing for a healthcare payer
- Facets — REQUIRED: claims module familiarity (encounters are derived from Facets claims data); Facets-to-encounter data validation
- X12 EDI knowledge: 837P, 837I, 837D (Professional, Institutional, Dental) — transaction structure, loops, segments
- 277CA (Claim Acknowledgement) and 999/TA1 validation
- Encounter submission & acceptance rules — Medicaid, Medicare Advantage, TRICARE, Marketplace
- Experience with Edifecs or equivalent EDI validation tooling
- 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
Enrollment / Membership (EDI 834 Focus):
- 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