Analyst, Data Exchange (Medical, Dental & Vision)

About the Role

Key Responsibilities

• Design, develop, and maintain data mappings and transformations for incoming and outgoing healthcare data files: 837/835 - claims & remittance, 270/271 - eligibility and responses, 278 - Prior Auth, 276/277 - claim status, 999/TA1 - file level acknowledgement as well as proprietary formats
• Collaborate with internal teams (e.g., Client Services, Claims, IT Development) and external partners (e.g., clearing houses or third-party administrators) to define data requirements and specifications
• Work with business teams and trading partners to onboard, test and certify new connections and transaction sets
• Develop and implement data validation rules and processes to ensure the accuracy, completeness, and consistency of exchanged data
• Proactively identify and resolve data discrepancies, errors, and rejections in a timely manner
• Perform root cause analysis for data issues and implement preventative measures
• Proactively monitor system status and Data Exchange management data to quickly identify potential abnormalities that might impact quality and accuracy
• Provide technical support and troubleshooting for data exchange issues, working with internal and external stakeholders to resolve problems
• Document data exchange processes, configurations, and troubleshooting steps
• Identify opportunities to optimize and automate data exchange processes, improving efficiency and reducing manual effort
• Stay current with industry best practices, new technologies, and regulatory requirements related to healthcare data exchange
• Generate reports on data exchange performance, error rates, and key metrics
• Analyze data trends to identify potential issues or areas for improvement
• Participate in projects with Data Exchange impacts including vendor changes, client migrations, and client add-on requests
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Requirements

• Bachelor's degree in Computer Science, Information Systems, Healthcare Informatics, or a related field. Equivalent work experience may be considered
• Knowledge of healthcare claim adjudication processes for medical, dental, and vision
• Strong knowledge and familiarity with EDI SNIP validations and one of the most widely used tools in the healthcare industry (e.g., EDIFECS)
• 2+ years of experience in data analysis, data integration, or EDI (Electronic Data Interchange) specifically within the healthcare industry
• Strong understanding of healthcare EDI transactions (e.g., 834 Enrollment, 837 Professional/Institutional/Dental Claims, 835 Remittance Advice)
• Excellent analytical, problem-solving, and critical thinking skills
• Familiarity with various file transfer protocols (FTP, SFTP, FTPS)
• Understanding of HIPAA compliance and other relevant healthcare regulations
• Strong attention to detail and a commitment to data accuracy
• Ability to analyze complex business problems to discover and resolve root causes
• Proficiency in SQL, Excel, JSON and other technical data skills preferred
• Strong communication skills with the ability to develop effective work relationships with internal and external stakeholders
• Self-motivated and detail-oriented problem solver
• Ability to handle multiple competing priorities in a dynamic environment and collaborate in a team