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.

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