Healthcare EDI Systems Analyst

The Healthcare EDI Systems Analyst is responsible for the implementation, support, monitoring, analysis, and optimization of Electronic Data Interchange (EDI) transactions used in healthcare operations. This role ensures the accurate, secure, and compliant exchange of healthcare data between providers, payers, clearinghouses, government agencies, and third-party vendors.

The analyst serves as the primary liaison between business stakeholders, healthcare operations teams, application support teams, and external trading partners to ensure HIPAA-compliant electronic healthcare transactions are processed efficiently and accurately. The position requires strong expertise in healthcare EDI standards, claims processing workflows, revenue cycle management, and healthcare information systems.

Key Responsibilities

EDI Operations & Transaction Management

• Monitor daily healthcare EDI transaction processing and error queues.

• Analyze, troubleshoot, and resolve EDI claim, eligibility, remittance, and authorization transaction failures.

• Ensure timely processing of inbound and outbound healthcare transactions.

• Manage transaction acknowledgments and reconciliation processes.

• Coordinate issue resolution with providers, payers, clearinghouses, and vendors.

• Support production environments with minimal business disruption.

Healthcare Claims & Revenue Cycle Support

Support and maintain healthcare transaction workflows including:

Claims Processing

• 837 Professional (837P)

• 837 Institutional (837I)

• 837 Dental (837D)

Eligibility & Benefits

• 270 Eligibility Inquiry

• 271 Eligibility Response

Claim Status

• 276 Claim Status Request

• 277 Claim Status Response

Prior Authorization

• 278 Health Care Services Review

Payments & Remittance

• 835 Electronic Remittance Advice (ERA)

• EFT Reconciliation

Enrollment

• 834 Benefit Enrollment and Maintenance

Acknowledgments

• 999 Implementation Acknowledgment, Compliance & Regulatory Support

• Ensure compliance with HIPAA EDI transaction standards.

• Support regulatory healthcare reporting requirements.

• Assist with CMS, Medicare, Medicaid, and commercial payer transaction compliance.

• Participate in audits and security reviews.

• Maintain compliance documentation and process controls.

• Support implementation of federal and state healthcare mandates.

Trading Partner Management

• Onboard and manage healthcare trading partners.

• Coordinate connectivity setup and certification testing.

• Validate EDI compliance against payer and clearinghouse specifications.

• Maintain healthcare trading partner profiles.

• Serve as escalation point for transaction issues.

Data Analysis & Reporting

• Perform root cause analysis on transaction failures and claims processing issues.

• Analyze data quality issues affecting reimbursement and member services.

• Create operational reports and transaction monitoring dashboards.

• Develop KPI reporting for EDI transaction performance.

• Bachelor's degree in Information Systems, Healthcare Informatics, Computer Science, Health Information Management, or a related field.

• Equivalent combination of education and experience may be considered.

Experience

• 3+ years of healthcare EDI experience.

• Experience supporting HIPAA X12 transactions.

• Experience with healthcare claims, eligibility, remittance, and enrollment processing.

• Experience working with providers, payers, clearinghouses, or healthcare technology organizations.

• Experience supporting revenue cycle management operations preferred.

Required Technical Skills

Healthcare EDI Standards

Strong knowledge of:

• ANSI X12 Healthcare Transactions

• HIPAA EDI Standards

• NCPDP Standards

• HL7

• FHIR APIs

• XML

• JSON

Healthcare Transaction Expertise

Hands-on experience with:

• 834 Enrollment

• 835 Remittance Advice

• 837 Claims, * IBM Sterling B2B Integrator

• Edifecs

• Optum Intelligent EDI

• OpenText

• Cleo Integration Cloud

• MuleSoft

• Boomi

• Cognizant TriZetto

• HealthEC

• Oracle Integration Cloud

Technical Competencies

• SQL development and analysis

• Healthcare data mapping

• EDI troubleshooting

• API integration support

• Data validation

• Healthcare claims processing systems

• Windows and Linux administration

• Scripting (PowerShell, Python, Shell)

Preferred Qualifications

• Certified Professional in Healthcare Information and Management Systems (CPHIMS)

• Healthcare Informatics certification

• Knowledge of Medicare and Medicaid programs

• Experience with healthcare clearinghouses

• FHIR and HL7 integration experience

• Experience supporting cloud integration platforms (Azure, AWS, Google Cloud)

• Knowledge of value-based care and population health data exchanges

Key Competencies

Technical Skills

• HIPAA EDI expertise

• Claims processing knowledge

• Revenue cycle management support

• Data integration and mapping

• System troubleshooting

• Healthcare application support

Business Skills

• Healthcare operations understanding

• Regulatory compliance knowledge

• Stakeholder management

• Vendor and payer collaboration

• Process improvement

Soft Skills

• Strong analytical thinking

• Excellent communication skills

• Attention to detail

• Ability to manage multiple priorities

• Problem-solving capabilities

• 270/271 Eligibility

• 276/277 Claim Status

• 278 Prior Authorization

• 999 Acknowledgments

• TA1 Interchange Acknowledgments