EDI & Claims Operational Analyst

Position Summary

The EDI and Claims Operations Analyst manages end-to-end EDI processes for Blue Zones Health claims operations, ensuring timely, accurate, and compliant data flow between providers, clearinghouses, health plans, and internal systems. The role also serves as the claims and EDI analytical partner to the Director, Delegated Operations and Optimization. In that capacity, it turns transaction data into insight that resolves escalations, improves data integrity, and reduces provider friction.

Budgeted Compensation: $85,000 - $100,000 USD Annually

Responsibilities

EDI Transaction Management

• Manage and monitor daily EDI transaction flows (837, 835, 834, 270/271, 276/277, 278) between provider groups, clearinghouses, and health plan trading partners within SLA.

• Ensure outbound data, including misdirected claims, encounters, and authorizations, is uploaded to the appropriate clearinghouses and trading partners on time.

• Investigate and resolve EDI file rejections, claim edits, and transaction errors, coordinating with IT and external trading partners to implement corrections.

• Reconcile claim submission and acceptance reports against clearinghouse and payer confirmations to identify and resolve discrepancies.

• Maintain EDI mapping specifications, trading partner agreements, and companion guides. Participate in testing for platform upgrades, connectivity changes, and new transaction sets.

Claims Operations and Payment

• Analyze pended, denied, or rejected claims tied to EDI transmission issues and recommend root-cause fixes to protect claims throughput and timeliness.

• Execute weekly provider check runs for accurate, timely release of funds, and review high-dollar claims above thresholds per BZH claims payment policy.

• Respond to and resolve provider-escalated inquiries related to claims, eligibility, authorizations, and EDI issues to reduce provider friction.

Authorization and UM Coordination

• Resolve claims pended or denied for authorization issues, such as missing, expired, or mismatched dates, CPT codes, units, or providers, in coordination with Utilization Management.

• Monitor authorization-related pend queues and aging to prevent backlog, and support 278 transaction processing between health plans, UM systems, and the claims platform.

• Trend authorization-driven claim issues by provider, service type, and health plan, and recommend fixes to matching logic, data entry standards, and provider education.

Provider Data and Contract Integrity

• Identify EDI rejections caused by provider data issues (NPI/TIN, taxonomy, address, payer ID) and route them to Provider Data Management for correction at the source.

• Validate 834 enrollment and roster file loads against PDM, and report discrepancies that affect claims payment or directory accuracy.

• Support contract configuration QA through test claims and post-implementation payment reviews to confirm new and amended contracts pay as intended.

• Monitor 835 remittance data for underpayments or fee schedule variances, and escalate configuration errors to the Director and Contract Coordinator.

Operational Reporting and Optimization Support

• Serve as the claims and EDI analytical partner to the Director, Delegated Operations and Optimization. Provide documented root-cause analysis for claims, authorization, and EDI escalations.

• Track and trend recurring escalations to identify systemic fixes, informing the Director’s process improvement work and health plan governance discussions.

• Own claims, authorization, and EDI metrics for operational dashboards, such as rejection rates, turnaround times, and auth-related pends. Support quarterly operational reviews.

• Prepare performance materials for executive health plan operating meetings, and document health plan-side issues such as encounter rejections and connectivity failures.

• Participate in Director-led optimization workgroups. Identify automation and RPA opportunities, such as rejection rework and reconciliation, with Product, Data, and IT.

• Maintain SOPs for EDI, claims, and payment processes, and draft technical content for provider and health plan communications on EDI changes.

Compliance and Audit

• Support internal and delegated audits by providing EDI transaction documentation, claims processing evidence, and authorization reconciliation records.

• Comply with all applicable federal, state, and local laws, and all Blue Zones Health policies, procedures, and codes of conduct.

Education & Experience

• Bachelor's degree in Health Information Management, Business Administration, Health Administration, or a related field, or equivalent combination of education and experience.

• 4-5+ years of experience in EDI operations, claims processing, or health plan/IPA claims administration.

• Hands-on experience with EDI transaction sets (837, 835, 834, 270/271, 276/277) and HIPAA 5010 standards.

• Experience with claims adjudication platforms (e.g., EZ-CAP, QNXT, Facets, or similar) strongly preferred.

• Experience working within an IPA, MSO, health plan, or managed care environment preferred.

Skills & Competencies

• Strong working knowledge of HIPAA transaction and code set standards and payer companion guides.

• Working knowledge of prior authorization and referral workflows and how authorizations link to claims adjudication.

• Understanding of provider data elements (NPI, TIN, taxonomy, payer IDs) and their impact on claims and EDI accuracy.

• Proficiency with EDI translator/mapping tools and clearinghouse portals.

• Advanced Excel skills (pivot tables, VLOOKUP/XLOOKUP) for reconciliation and reporting; SQL and PowerBI a plus.

• Strong root-cause analysis and problem-solving skills with attention to detail in high-volume, data-intensive environments.

• Ability to manage multiple priorities and meet deadlines in a fast-paced claims operations setting.

• Familiarity with CMS and state Medicaid/Medicare regulatory requirements related to claims processing a plus.