Healthcare EDI Business Analyst – Eligibility

Position: Healthcare EDI Business Analyst – 270/271 Eligibility & Benefits
Job Title:

Healthcare EDI Business Analyst – 270/271 Eligibility & Benefits

Summary
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, revenue cycle/eligibility operations, and engineering to ensure accurate, compliant, and user-friendly eligibility verification workflows.

Key Responsibilities
Own the end-to-end strategy for eligibility data presentation, including EB segment prioritization and simplification of complex benefit structures.
Define the canonical internal data model for eligibility and benefit information across products and workflows.
Lead discovery sessions with revenue cycle, registration, and clinical stakeholders to determine how eligibility, copay, deductible, coinsurance, and plan limitations should appear in portals, PMS/EHR screens, and reports.
Analyze 270/271 X12 files (loops, segments, codes) to document parsing logic for EB, DTP, AMT, HSD, and related segments.
Translate business needs into functional and mapping specifications, including data dictionaries, field-level requirements, and error-handling rules.
Establish and maintain business rules to normalize and prioritize multiple EB segments (e.g., office visits vs. surgery vs. preventive services).
Design and document UI/UX guidelines for displaying eligibility data consistent with CAQH CORE 270/271 rules.
Partner with EDI and infrastructure teams to support connectivity, trading partner onboarding, and monitoring of 270/271 transactions, including AAA error handling.
Create and execute test cases for eligibility flows, including positive/negative scenarios, regression testing, and validation against companion guides and CORE rules.
Collaborate with data/BI teams to define downstream use of eligibility data for dashboards and analytics (e.g., hit rate, timeliness, patient responsibility).
Document current and future state workflows, process maps, and SOPs for front-end staff and revenue cycle teams.
Ensure compliance with HIPAA, payer companion guides, and CAQH CORE operating rules.
Provide subject matter expertise and training to product, operations, and support teams on interpreting 270/271 responses.

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

Preferred Qualifications
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 in Agile product teams, including writing user stories and acceptance criteria.
Exposure to other HIPAA X12 transactions (835, 837, 276/277, 834) to understand end-to-end data flow.

✅ Why This Role Matters
This position is critical for ensuring that eligibility verification is not only technically accurate but also operationally intuitive for front-line staff. By bridging technical EDI parsing with user-friendly workflows, the Healthcare EDI Business Analyst helps reduce claim denials, improve patient financial transparency, and streamline revenue cycle operations.

#Healthcare Jobs, #Business Analyst #EDIJobs #X12

Transactions