EDI Healthcare Analyst – Remote (US Only) || W2 Only ||

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