EDI Eligibility Analyst III

Liviniti; Chicago (IL); Remote; USD 90,000 - 120,000; Full time

Job summary

Liviniti, LLC is seeking an EDI Eligibility Analyst III in Chicago, IL, with REMOTE options. This senior role drives complex eligibility work, ensures data integrity, and acts as escalation and quality backstop for eligibility accuracy.

You will collaborate with EDI, Implementation, Adjudication, and QA teams, test and monitor systems, and support audits while maintaining HIPAA compliance and onboarding new eligibility feeds.

Qualifications

• Bachelor’s degree or equivalent experience.
• 5+ years in eligibility/EDI/healthcare operations.
• PBM or health plan experience strongly preferred.
• Experience supporting production EDI and Eligibility environments.

Responsibilities

• Ensure the quality of eligibility driving claim adjudication.
• Maintain data integrity of upstream eligibility feeds.
• Test, monitor, issue resolution, and escalations.
• Analyze complex eligibility issues impacting claims and member coverage.
• Support audits and internal reviews related to eligibility accuracy.
• Onboard new eligibility feeds with clients and vendors.

Skills

EDI expertise

Analytical skills

Independent worker

Communication skills

Multitasking

Eligibility knowledge

Education

Bachelor’s degree

Tools

270/271 standards

X12 files

ETL tools

SQL & Excel

Relational/No-SQL DBs

Snowflake/AWS/Azure

Zendesk/JIRA/ADO

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

EDI Eligibility Analyst III

Full Time Supervisory Level Chicago, IL, US

PBM Eligibility Analyst III - REMOTE

Role and Responsibilities

The Eligibility Analyst III will execute and support complex eligibility work within established ownership. This role serves as the senior eligibility analyst, escalation support, and quality backstop for eligibility accuracy and production stability. The Eligibility Analyst IIIis required to perform the following duties and professionally undertake the following responsibilities:

• Accountable for the quality of eligibility driving claim adjudication.
• Responsible for the data integrity of upstream client eligibility to downstream eligibility shared with vendors and systems.
• Responsible for testing, monitoring, issue resolution, and escalations.
• Analyze and resolve complex eligibility issues impacting claims, accumulators, and member coverage.
• Support root cause analysis for recurring eligibility defects and data discrepancies.
• Serve as escalation support for Analyst I/II eligibility issues.
• Partner with EDI, Implementation, Adjudication, and QA teams during testing and production support.
• Validate eligibility data across multiple systems and identify cross-functional impacts.
• Review eligibility outputs for accuracy and adherence to standards.
• Maintain and enhance eligibility documentation and processing standards.
• Maintain profiles on TPA/TPVs and ensure alignment with Liviniti strategies.
• Support audits and internal reviews related to eligibility accuracy.
• Monitor production trends and identify areas of risk or improvement.
• Ensure compliance with HIPAA, security, and Liviniti standards.
• Work closely with clients, vendors, and internal stakeholders to onboard new eligibility feeds and enhancements.
• Identify opportunities for automation and process improvement within eligibility workflows.
• Abides by all obligations under HIPAA related to Protected Health Information (PHI).
• If a HIPAA violation is discovered, whether individually or by another, you must report the violation to the Compliance Officer and/or Human Resources.
• Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company.
• Flexibility to understand, appreciate, and embrace that this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

What We Have to Offer

Our benefits package is designed to keep our employees happy and healthy - physically, mentally and financially.

• Disability and Life insurance
• Employee Assistance Program
• Remote work options
• Generous Paid-Time Off
• Annual Reviews and Development Plans
• Retirement Plan with company match immediately 100% vested

Required Skills and Competencies

• Expert in EDI with a deep understanding of eligibility data structures and workflows
• Strong analytical and problem-solving skills
• Ability to work independently on complex issues
• Strong judgment within defined processes and escalation paths
• Clear written and verbal communication
• Ability to manage multiple concurrent issues
• Familiarity with eligibility impacts on claims adjudication and member benefits

Tools, Files, and technical skills and competencies

• Strong knowledge and working experience with transaction/file standards (270/271, 834, 835)
• Ability to read, interpret, and troubleshoot raw X12 files.
• Knowledge of data integration and ETL tools.
• Strong data analysis skills (SQL, Excel, and other standard tools)
• Working knowledge of various Database technologies (Relational-SQL, No-SQL, Warehouses, Cloud-based)
• Ability to translate technical findings into recommendations for cross-functional stakeholders.
• Experience with cloud data platforms (e.g. Snowflake, AWS, Azure)
• Experience with operational ticketing and workflow management systems (e.g., Zendesk, JIRA, Azure DevOps, or similar tools)

Supervisory Responsibility

• Informal mentoring and support of Analyst I/II roles
• Provide guidance to the team on configuring and maintaining eligibility file mappings for inbound data feeds.

Position Type and Expected Hours of Work

• Some flexibility in hours is allowed, but the employee must be available during the "core" work hours of 8:00 AM to 5:00 PM CT. We cover clients from the West to the East Coast; work times must be adjusted to cover meetings in all time zones. Ability to work extended hours, weekends, and holidays in accordance with industry demands.

Travel

Minimal travel expected for this position.

Qualifications and Education Requirements

• Bachelor’s degree or equivalent experience
• 5+ years of eligibility, EDI, or healthcare operations experience
• PBM or health plan experience strongly preferred
• Experience supporting production EDI and Eligibility environments

Liviniti, LLC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, Liviniti, LLC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Liviniti, LLC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Liviniti, LLC employees to perform their job duties may result in discipline up to and including discharge. EOE M/F/D/V