• 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.

• 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

• 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 and competencies

Supervisory Responsibility

Position Type and Expected Hours of Work

Travel

Minimal travel expected for this position.

Qualifications and Education Requirements