EDI/Eligibility Analyst III

Liviniti; United States; Remote; USD 70,000 - 110,000; Full time

Benefits offered by this job

Disability & Life insurance

Employee Assistance Program

Remote work options

Paid Time Off

Development plans & reviews

Retirement plan with company match

Job summary

Liviniti is seeking an experienced EDI/Eligibility Analyst III to join our remote team in the United States. This senior role drives complex eligibility work, ensuring data integrity across multiple systems and collaborating with clients, vendors, and internal teams.

You'll optimize eligibility workflows, support testing and production, and maintain documentation while upholding HIPAA and security standards. 5+ years in eligibility/EDI within PBM or health plans is preferred.

Qualifications

• 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.

Responsibilities

• Execute and support complex eligibility work within established ownership.
• Serve as escalation support and quality backstop for eligibility accuracy.
• Test, monitor, issue resolution, and escalation for eligibility issues.
• Analyze and resolve complex eligibility issues impacting claims, accumulators, and member coverage.
• Identify opportunities for automation and process improvement within eligibility workflows.

Skills

EDI expertise

Analytical skills

Independence

Decision making

Communication

Multitasking

Eligibility impact

Education

Bachelor’s degree or equivalent experience

Tools

SQL

Excel

ETL tools

Zendesk

JIRA

Azure DevOps

Snowflake

AWS

Azure

Job description

We wanted a PBM that worked better. So we took a bold approach...

When we set out in 2011 as Southern Scripts to reshape pharmacy benefit management, it was because we believed there was a better way. Throughout our journey, we’ve never been afraid to challenge widely accepted industry practices or to pioneer a better model. We see that the concept of “transparency” is gaining momentum. At Liviniti, we’ve been delivering it for more than a decade.

Liviniti, grew from a commitment to offer an uncomplicated approach to managing pharmacy benefits. One based on transparency, affordability, quality, service and innovation. Our name describes the future that we envision - one with infinite possibilities for better living.

Join a team that is reshaping pharmacy benefit management! At Liviniti, we give people the runway to do their best work. We seek people who analyze, challenge and think outside the box – and reward them with an environment and benefits that support their professional and personal goals.

We are currently seeking an EDI/Eligibility Analyst III. This is a fully remote/work from home position.

Role and Responsibilities

The EDI/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 EDI/Eligibility Analyst III is 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

• 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 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 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 employees to perform their job duties may result in discipline up to and including discharge. EOE M/F/V/D