Requirement Healthcare EDI Business Systems Analyst (BSA) 837 & Facets
Position Overview
We are looking for an experienced Healthcare EDI Business Systems Analyst (BSA) with strong knowledge of Healthcare Claims, HIPAA EDI transactions, 837 Professional (837P), 837 Institutional (837I), and TriZetto Facets.
The ideal candidate should have a strong understanding of healthcare payer operations and be capable of analyzing business and system requirements, reviewing EDI transactions at the loop/segment/element level, understanding Facets claim processing, identifying data or processing gaps, and translating business needs into clear functional and technical requirements.
The resource will work closely with Business, EDI, Development, QA, Facets Configuration, Operations, and Product teams to support healthcare claims initiatives.
Required Skills
* 5+ years of experience in Healthcare IT, Business Systems Analysis, Claims, or EDI.
* Strong functional knowledge of 837 Professional (837P) and Institutional (837I) healthcare claims.
* Strong understanding of HIPAA X12 5010 transactions and EDI file structures.
* Ability to analyze 837 loops, segments, elements, qualifiers, and values and translate EDI requirements into business/system requirements.
* Strong hands-on functional experience with TriZetto Facets, particularly Facets Claims.
* Good understanding of Professional and Institutional claim processing and adjudication within Facets.
* Ability to analyze and document requirements involving key claim information, including:
* Billing, Rendering, Referring, Attending and Service Facility Providers
* Subscriber and Patient information
* Member IDs and eligibility information
* Diagnosis codes
* CPT/HCPCS and procedure codes
* Revenue codes
* Place of Service
* Dates of service
* Claim-level and service-line charges
* COB / Coordination of Benefits information
* Claim adjustments, denials and payment information
* Ability to map incoming 837 claim data to corresponding fields and processing logic in Facets.
* Experience analyzing business rules, system behavior, data mappings and payer-specific processing requirements.
* Strong understanding of the complete healthcare claims lifecycle:
837 Submission EDI Validation 999/277CA Facets Claim Load Claim Adjudication Payment/Denial 835 Remittance
* Knowledge of 999 and 277CA acknowledgments, including claim and transaction rejection analysis.
* Knowledge of 835 remittance transactions and claim-to-remittance reconciliation.
* Experience with Medicaid and/or Medicare claims processing is highly preferred.
* Experience working with payer-specific EDI companion guides, business rules, mapping documents and implementation requirements.
* Ability to write Business Requirements Documents (BRDs), Functional Requirements Documents (FRDs), user stories, acceptance criteria, process flows, data mappings and functional specifications.
* Experience conducting requirement-gathering sessions and working directly with business and technical stakeholders.
* Ability to perform impact analysis and gap analysis for new requirements and system changes.
* Ability to support QA teams by reviewing test scenarios, expected results and requirements traceability.
* Ability to analyze production and testing issues and determine whether the root cause is related to:
* Source 837 data
* EDI validation
* EDI translation/mapping
* Business rules
* Facets configuration
* Claim adjudica
Never miss an opportunity! Create an alert based on the job you applied for.
