Analyst, Data Exchange - Claim Ops (TPA)

Location: Hybrid 3 days (offices in NYC, Denver, CO and Charlotte, NC area)

Position Summary:

The Data Exchange Analyst is a crucial member of our Data Operations team, responsible for ensuring the accurate, efficient, and secure exchange of healthcare data between Capital Rx – JUDI Health and its various partners, including employers, providers, and other TPAs. This role focuses on the technical aspects of data integration, file transformation, error resolution, and ongoing monitoring of data feeds for medical, dental, and vision claims. The ideal candidate will possess a strong understanding of healthcare data formats, excellent analytical skills, and a commitment to data integrity and compliance.

Key Responsibilities:

Data Integration & Mapping:

• Design, develop, and maintain data mappings and transformations for incoming and outgoing healthcare data files: 837/835 - claims & remittance, 270/271 – eligibility and responses, 278 – Prior Auth, 276/277 – claim status, 999/TA1 – file level acknowledgement as well as proprietary formats
• Collaborate with internal teams (e.g., Client Services, Claims, IT Development) and external partners (e.g., clearing houses or third-party administrators) to define data requirements and specifications
• Work with business teams and trading partners to onboard, test and certify new connections and transaction sets

Data Quality & Validation:

• Develop and implement data validation rules and processes to ensure the accuracy, completeness, and consistency of exchanged data
• Proactively identify and resolve data discrepancies, errors, and rejections in a timely manner
• Perform root cause analysis for data issues and implement preventative measures

Monitoring & Support:

• Proactively monitoring system status and Data Exchange management data to quickly identify potential abnormalities that might impact quality and accuracy
• Provide technical support and troubleshooting for data exchange issues, working with internal and external stakeholders to resolve problems
• Document data exchange processes, configurations, and troubleshooting steps

Process Improvement & Automation:

• Identify opportunities to optimize and automate data exchange processes, improving efficiency and reducing manual effort
• Stay current with industry best practices, new technologies, and regulatory requirements related to healthcare data exchange

Reporting & Analysis:

• Generate reports on data exchange performance, error rates, and key metrics
• Analyze data trends to identify potential issues or areas for improvement
• Analyze data trends to identify potential issues or areas for improvement
• Participate in projects with Data Exchange impacts including vendor changes, client migrations, and client add-on requests

Required Qualifications:

• Bachelor's degree in Computer Science, Information Systems, Healthcare Informatics, or a related field. Equivalent work experience may be considered
• Knowledge of healthcare claim adjudication processes for medical, dental, and vision
• Strong knowledge and familiarity with EDI SNIP validations and one of the most widely used tools in the healthcare industry (e.g., EDIFECS)
• 2+ years of experience in data analysis, data integration, or EDI (Electronic Data Interchange) specifically within the healthcare industry
• Strong understanding of healthcare EDI transactions (e.g., 834 Enrollment, 837 Professional/Institutional/Dental Claims, 835 Remittance Advice)
• Excellent analytical, problem-solving, and critical thinking skills
• Familiarity with various file transfer protocols (FTP, SFTP, FTPS)
• Understanding of HIPAA compliance and other relevant healthcare regulations
• Strong attention to detail and a commitment to data accuracy
• Ability to analyze complex business problems to discover and resolve root causes
• Proficiency in SQL, Excel, JSON and other technical data skills preferred
• Strong communication skills with the ability to develop effective work relationships with internal and external stakeholders
• Self-motivated and detail-oriented problem solver
• Ability to handle multiple competing priorities in a dynamic environment and collaborate in a team

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.