EDI & Claims Optimization Analyst

Blue Zones Health; United States; On-site; USD 85,000 - 100,000; Full time

Job summary

Blue Zones Health is seeking an EDI & Claims Operational Analyst to manage end-to-end EDI processes for claims operations in the United States. You will ensure timely, accurate data flows between providers, clearinghouses, health plans, and internal systems while serving as the analytical partner to optimize performance.

You will analyze transactions, resolve escalations, and drive improvements in data integrity and provider experience, supporting the Director with insights, dashboards, and

Qualifications

• Bachelor's degree in Health Information Management, Health Administration, or related field.
• 4–5+ years in EDI operations, claims processing, or health plan administration.
• Hands-on experience with EDI transaction sets (837, 835, 834, 270/271, 276/277) and HIPAA 5010 standards.
• Experience with claims adjudication platforms (EZ-CAP, QNXT, Facets) strongly preferred.
• Experience in IPA/MSO/managed care environment preferred.
• Strong working knowledge of HIPAA transaction and code set standards and payer companion guides.
• 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 in high-volume data 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.

Responsibilities

• Manage end-to-end EDI transaction flows (837, 835, 834, 270/271, 276/277, 278) 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.
• 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.
• 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.
• 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 escalated configuration errors to the Director and Contract Coordinator.
• 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.

Skills

EDI operations

HIPAA standards

Excel

SQL

Power BI

Data analysis

Root-cause analysis

Attention to detail

Education

Bachelor's degree in Health Information Management, Health Administration, Business Administration, or related field

Tools

EZ-CAP

QNXT

Facets

Clearinghouse portals

Job description

Blue Zones Health is seeking an EDI & Claims Operational Analyst to manage end-to-end EDI processes for claims operations in the United States. You will ensure timely, accurate data flows between providers, clearinghouses, health plans, and internal systems while serving as the analytical partner to optimize performance.

You will analyze transactions, resolve escalations, and drive improvements in data integrity and provider experience, supporting the Director with insights, dashboards, and