Business Analyst, Healthcare EDI

Essen Medical Associates

About The Position

The Healthcare EDI Business Analyst is responsible for analyzing ANSI X12 270/271 eligibility and benefits transactions, defining business and technical requirements, and designing strategies to parse and present coverage, copay, coinsurance, deductible, and out-of-pocket data to end users. This role bridges product, RCM/eligibility operations, and engineering to ensure accurate, compliant, and user-friendly eligibility verification workflows.

Requirements

3–5+ years of experience as an EDI Analyst, Business Analyst, or similar role in healthcare, with hands-on work on ANSI X12 transactions.
Strong, demonstrable experience with 270/271 eligibility and benefits transactions, including reading raw X12 files and understanding loops (2000, 2100, 2110) and EB/EQ segments.
Solid understanding of health insurance concepts: plan types, covered services, service types, payer types, primary & secondary plans, HMOs, copay, coinsurance, deductibles, OOP maximums, accumulators, and benefit limitations.
Experience creating functional specs, mapping documents, and business rules for parsing and integrating EDI data into PMS/EHR, clearinghouse, or custom applications.
Proficiency with advanced Excel and familiarity with SQL or similar tools for validating and profiling eligibility data.
Knowledge of HIPAA transaction standards and CAQH CORE eligibility & benefits rules.
Strong communication skills and ability to translate technical EDI content into clear requirements and user-facing documentation.

Nice To Haves

Experience in provider revenue cycle, registration, scheduling, or prior authorization operations.
Prior work with payer or clearinghouse 270/271 companion guides and real-time eligibility APIs.
Background working in Agile product teams, writing user stories and acceptance criteria for eligibility features.
Exposure to other HIPAA X12 transactions (835, 837, 276/277, 834) to understand end-to-end data flow.

Responsibilities

Owns the end-to-end strategy for eligibility data presentation, including which EB segments to surface, how to rank conflicting benefits, and how to simplify complex benefit structures for front-line users."
Defines the canonical internal data model for eligibility and benefit information used across products and workflows.
Lead discovery with revenue cycle, registration, and clinical stakeholders to define how eligibility, copay, deductible, coinsurance, and plan limitations should appear in eCares portal and/or PMS/EHR screens, and reports.
Analyze 270/271 X12 files (loops, segments, codes) to document detailed parsing logic for EB, DTP, AMT, HSD and related segments covering benefit levels, service types, and financial accumulators.
Translate business needs into functional and mapping specifications for engineering or integration teams, including data dictionaries, field-level requirements, and error-handling rules.
Define and maintain business rules to normalize and prioritize multiple EB segments (e.g., selecting primary copay/coinsurance for office visits vs. surgery vs. preventive services).
Design and document UI/UX guidelines for displaying eligibility data (e.g., base/remaining deductible, OOP, copay by service type) consistent with CAQH CORE 270/271 data content rules.
Partner with EDI and infrastructure teams to support connectivity, trading partner onboarding, and monitoring of 270/271 transactions, including handling rejections and AAA error segments.
Create and execute test cases for 270/271 flows, including positive/negative scenarios, regression testing, and validation against companion guides and CORE rules.
Work with data/BI teams to define and validate downstream use of eligibility data for dashboards and analytics (e.g., eligibility hit rate, verification timeliness, estimated patient responsibility).
Document current and future state eligibility workflows, process maps, and standard operating procedures for front-end staff and revenue cycle teams
Ensure compliance with HIPAA, payer companion guides, and CAQH CORE operating rules for eligibility and benefits transactions.
Provide subject matter expertise and training to product, operations, and support teams on interpreting 270/271 responses and resolving eligibility-related issues.