EDI Healthcare Analyst

Role OverviewWe 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 DoThe 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 FitThis role requires strong technical and domain expertise in EDI, healthcare payer domain knowledge, and experience with Edifecs or equivalent EDI validation tooling.RequirementsExperience in encounter data processing, EDI submission, and reconciliation testing for a healthcare payerX12 EDI knowledge: 837P, 837I, 837D (Professional, Institutional, Dental)Facets — REQUIRED: claims module familiarity (encounters are derived from Facets claims data); Facets-to-encounter data validationSQL for encounter data validation (claim header, detail, member eligibility cross-checks)TOSCA or Robot Framework test automationHealthcare payer domain knowledge including CMS encounter submission rules and state-specific companion guidesFacets — REQUIRED: membership/enrollment module testing, subscriber/member configuration, and 834-to-Facets data flow validationX12 EDI: 834 (Benefit Enrollment & Maintenance) — full transaction expertiseExperience with member add/change/term, dependent handling, dual-enrollment scenariosKnowledge of retroactive adjustments and deeming logic (Medicaid/MMP/Dual)820 (Premium Payment) validation linkageMember 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 toolsLOB knowledge: Medicaid, Medicare Advantage, Duals/MMP, TRICARE, MarketplaceBenefitsW2 employmentHourly rate of $40Originally posted on Himalayas