Senior EDI Operations Analyst - Eligibility SME

Senior EDI Operations Analyst - Eligibility      

Role and Responsibilities

The Senior EDI Operations Analyst (Remote) – Eligibility oversees and optimizes electronic data exchange (EDI) processes related to eligibility and enrollment. This role involves managing HIPAA X12 EDI transactions (834, 270/271, etc.), troubleshooting integration issues, improving data mapping accuracy, and ensuring compliance with industry regulations. The ideal candidate will work cross-functionally with IT, operations, payers, vendors, and third-party administrators (TPAs) to enhance data quality, system performance, and process automation.

Key Responsibilities

• Drive the end-to-end process of eligibility file transfers, ensuring seamless and efficient data exchanges between internal systems and external partners.
• Lead cross-functional initiatives to enhance data integration, mapping accuracy, and overall system performance by overseeing the mapping, transformation, and integration of complex file types, including 834, XML, fixed-width, delimited, and proprietary formats.
• Design and implement advanced eligibility file processes to streamline operations and reduce error rates.
• Identify opportunities for automation and process improvements, leveraging cutting-edge tools and methodologies.
• Serve as the subject matter expert for troubleshooting advanced data exchange issues, ensuring timely resolution.
• Evaluate and recommend tools and technologies to improve eligibility file processing and data integrity.
• Partner with internal teams, clients, and external vendors to define and maintain eligibility file specifications, transmission protocols, and data requirements.
• Build and maintain strong relationships with key stakeholders to ensure the timely resolution of issues and continuous improvement of processes.
• Provide mentorship and technical guidance to junior analysts and specialists, fostering a culture of learning and growth within the team.
• Lead training sessions to enhance team competencies in data mapping, file integration, and error resolution.
• Ensure adherence to Liviniti’s privacy and security standards, including compliance with HIPAA and other relevant regulations.
• Develop and maintain comprehensive documentation of processes, ensuring transparency and accountability.
• Provide detailed reporting and insights to senior leadership on file performance metrics, process improvements, and key accomplishments.

Troubleshooting & Issue Resolution

• Investigate and resolve errors in EDI file processing, transaction failures, and data mismatches.
• Analyze EDI logs, audit trails, and error reports to diagnose root causes and implement corrective actions.
• Provide technical support and guidance to internal teams and external partners regarding EDI eligibility workflows.
• Work with developers and system analysts to troubleshoot system integration issues and enhance automation.

Compliance & Regulatory Standards

• Ensure EDI transactions comply with HIPAA 5010, ACA, CMS, and payer-specific guidelines.
• Maintain eligibility file processing security and adherence to data privacy policies.
• Stay current with regulatory changes affecting EDI transactions and eligibility standards.
• Support internal and external audits related to EDI eligibility operations.

Process Improvement & Automation

• Identify opportunities to improve EDI workflows and reduce manual intervention.
• Partner with IT teams to implement EDI process automation, system enhancements, and data validation rules.
• Develop standard operating procedures (SOPs) and best practices for EDI file processing.
• Assist in testing and deploying system upgrades, new integrations, and business rule changes.

What We Have to Offer

Our benefits package is deigned to keep our employees happy and healthy - physically, mentally and financially.

• Medical, Dental, Vision Insurance
• Disability and Life Insurance
• Employee Assistance Program
• Remote Work Options
• Generous Paid-Time Off
• Annual Reviews and Development Plans
• Retirement Plan with company match immediately 100% Vested
  
  

Required Skills and Competencies

• Advanced Technical Proficiency

1. Expert-level knowledge of eligibility file formats, data mapping, and systems integration.
2. Proficiency in SQL for advanced data querying, analysis, and troubleshooting eligibility data discrepancies.
3. Hands-on experience with file transmission protocols (e.g., FTP/Secure FTP, VPN) and automation tools.
4. Mastery of data transformation and validation logic.
5. Experience working with EDI platforms and tools.
6. Familiarity with API-based data exchange and integration solutions.
7. Knowledge of cloud-based EDI environments (AWS, Azure, etc.).
8. Experience with automated testing and monitoring tools for EDI transactions.

• Leadership and Problem-Solving

1. Proven track record of leading complex projects with multiple stakeholders.
2. Exceptional analytical and problem-solving skills to address high-level challenges and implement sustainable solutions.
3. Ability to manage competing priorities in a high-pressure, deadline-driven environment.

• Communication and Collaboration

1. Excellent written and verbal communication skills to effectively interact with senior leaders, clients, and vendors.
2. Strong interpersonal skills with a focus on relationship building and stakeholder management.

• Adaptability and Vision

1. Demonstrated ability to adapt to changing business needs and drive strategic initiatives forward.
2. Forward-thinking approach to process improvement and innovation.

Position Type and Expected Hours of Work

Full-time/Salaried/Exempt. Flexibility is required to cover meetings and activities across multiple time zones. Occasional extended hours, weekends, and holidays may be necessary to meet industry demands.

Travel

This position has minimal travel expectations.

Required Education and Experience

• Bachelor’s degree in business, Information Systems, Data Analytics, or a related field. (Master’s degree preferred)
• Minimum of 10+ years of experience in eligibility management, data integration, or a similar field.
• Extensive experience working with file formats such as 834, XML, and proprietary eligibility data formats.
• Proven expertise in SQL, data mapping, and troubleshooting complex file transmission issues.
• Familiarity with PBM claims adjudication processes and healthcare data standards.
• Advanced proficiency in Excel, including using macros, pivot tables, and complex formulas.

Certification in project management (e.g., PMP, Six Sigma) or process improvement is highly desirable.

Liviniti, LLC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, Liviniti, LLC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Liviniti, LLC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Liviniti, LLC employees to perform their job duties may result in discipline up to and including discharge.  EOE M/F/D/V