Eligibility Analyst III
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Job Description
Eligibility Analyst III ensuring quality of eligibility data for claim adjudication. Supporting testing, monitoring, and resolution of complex eligibility issues within healthcare operations.
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).
Requirements:
- Bachelor’s degree or equivalent experience
- 5+ years of eligibility, EDI, or healthcare operations experience
- Strong SQL & Excel skills
- PBM or health plan experience strongly preferred
- Experience supporting production EDI and Eligibility environments
Benefits:
- Medical, Dental, Vision insurance
- 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
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