Role Description
The EDI Technical Analyst is responsible for the analysis, implementation, support, and optimization of Electronic Data Interchange (EDI) transactions within a healthcare payer environment. This role serves as a liaison between business stakeholders, trading partners, vendors, and technical teams to ensure the accurate exchange of healthcare data. The analyst supports HIPAA-compliant transactions, troubleshooting, testing, implementation, and ongoing maintenance of EDI processes to improve operational efficiency and data integrity.
Key Responsibilities
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EDI Analysis & Support
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Analyze, configure, implement, and support healthcare EDI transactions including:
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834 Benefit Enrollment and Maintenance
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837 Professional, Institutional, and Dental Claims
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835 Electronic Remittance Advice
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270/271 Eligibility Inquiry and Response
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276/277 Claim Status Inquiry and Response
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278 Prior Authorization
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820 Premium Payments
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Monitor daily EDI processing and resolve transaction failures, rejections, and data integrity issues.
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Conduct root cause analysis and recommend corrective actions for production issues.
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Collaborate with business and operational teams to identify EDI requirements and system enhancements.
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Technical Analysis
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Analyze inbound and outbound EDI files and transaction sets for compliance with HIPAA standards.
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Create and maintain mapping specifications, technical documentation, and data flow diagrams.
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Perform impact assessments for system upgrades, regulatory changes, and business initiatives.
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Support integration between payer core administration systems (e.g., Facets, QNXT, HealthRules, NetworX) and external trading partners.
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Testing & Implementation
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Coordinate and execute unit, system, integration, and user acceptance testing.
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Develop test plans, test cases, and validation procedures.
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Facilitate onboarding of new providers, clearinghouses, employer groups, and vendor trading partners.
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Validate EDI transaction accuracy during implementation and system upgrades.
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Regulatory Compliance
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Ensure compliance with HIPAA X12 standards and CMS regulations.
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Stay informed of industry changes affecting EDI transactions and healthcare interoperability.
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Support audit requests and regulatory reporting activities.
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Stakeholder Collaboration
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Partner with business analysts, developers, operations teams, providers, clearinghouses, and external vendors.
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Serve as a subject matter expert for EDI-related processes and transaction troubleshooting.
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Provide production support and participate in issue resolution meetings.
Qualifications
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Bachelor's degree in Information Systems, Healthcare Administration, Computer Science, or equivalent work experience.
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3+ years of healthcare EDI experience within a payer organization.
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Strong knowledge of HIPAA X12 transaction sets (834, 837, 835, 270/271, 276/277, 278, 820).
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Experience working with healthcare claims, enrollment, eligibility, provider, and payment processes.
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Proficiency in analyzing EDI files and troubleshooting transaction errors.
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Experience with SQL and database querying.
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Understanding of healthcare payer operations and managed care concepts.
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Strong analytical, problem-solving, and communication skills.
Preferred Qualifications
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Experience with payer platforms such as Facets, QNXT, or HealthRules Payor.
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Experience with EDI tools such as IBM Sterling, Edifecs, BizTalk, or Cleo.
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Knowledge of XML, JSON, APIs, and healthcare interoperability standards.
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Experience supporting Medicare, Medicaid, and Commercial lines of business.
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Familiarity with Agile methodologies and project management practices.
Key Competencies
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EDI Transaction Management
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HIPAA Compliance
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Healthcare Claims Processing
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Trading Partner Management
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Root Cause Analysis
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Requirements Gathering
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System Integration
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SQL and Data Analysis
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Testing and Validation
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Technical Documentation
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Cross-Functional Collaboration
Benefits
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Choice of multiple health and dental plans with nationally recognized networks.
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Vision benefits, a total wellness program, and an employee assistance program.
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Competitive wages and retirement savings plans.
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Company-paid disability and life insurance.
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Pre-tax savings opportunities (HSA and/or FSA).
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Professional development offerings and opportunities for remote work.
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A generous paid-time-off program.
Company Description
At Tegria, we bring bold ideas and breakthroughs to improve care, technology, revenue, and operations in ways that move healthcare organizations from patient-centered to human-centered. We are helping healthcare put people first—both patients and those who dedicate their lives to delivering care.
Tegria is an equal employment opportunity employer and provides equal employment opportunities (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. All qualified candidates are encouraged to apply.
