Note: The job is a remote job and is open to candidates in USA. Liviniti is hiring a PBM Eligibility Analyst III to execute and support complex eligibility work, serving as a senior analyst, escalation resource, and quality backstop. The role maintains eligibility data accuracy and production stability, resolves complex issues, and partners with clients, vendors, and internal teams on testing, onboarding, compliance, and process improvement.
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
- 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
Skills
- 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
- 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)
- Bachelor's degree or equivalent experience
- 5+ years of eligibility, EDI, or healthcare operations experience
- Strong SQL & Excel skills
- Experience supporting production EDI and Eligibility environments
- PBM or health plan experience strongly preferred
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
Company Overview