EDI Healthcare Analyst – Remote (US Only) || W2 Only ||
Xlysi•Dallas, TX
•Remote
About The Position
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.
Requirements
- Experience in encounter data processing, EDI submission, and reconciliation testing for a healthcare payer.
- Facets 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.
- Facets 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.
Responsibilities
- Encounter data processing, EDI submission, and reconciliation testing for a healthcare payer.
- Facets 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.
- Facets 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
- No Benefits
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
