Enterprise Rules & Edits Analyst
Core
Translate complex payer and government requirements into accurate, high-performing claim edits and authorization logic to improve clean claim rates and reduce denials.
Role type
Enterprise Rules & Edits Analyst
Builds
Claim edit and authorization rule configurations for healthcare providers
Domain
Healthcare revenue cycle management and medical billing
Deliverable
production ML models | product features | dashboards & analysis
Required skills
Healthcare billing and coding expertise, EDI 837/835/278 data analysis, SQL database querying, Power BI visualization, complex Excel formula building, regulatory policy interpretation, rule logic design, unit and acceptance testing, process documentation
Preferred skills
CPC certification
Technologies
SQL, Power BI, Excel
Responsibilities
Build, validate, and deploy claim edit and authorization rule configurations; Configure system settings and execute testing; Translate payer and government requirements into structured rule logic; Analyze EDI data to identify trends and root causes; Partner with clients to optimize rule configurations; Develop sustainable processes and documentation for rule maintenance
Seniority
Mid-level, hands-on IC