EOB and Auditing Technical Analyst

Job Summary: The EOB and Auditing Technical Analyst supports the development, validation, and maintenance of Explanation of Benefits (EOB) processes across all Lines of Business. This role works closely with claims operations, auditing teams, and data/IT partners to ensure accurate EOB data mapping, regulatory alignment, and high‑quality output to members, providers, and self-funded employer groups. The EOB Auditing Technical Analyst assists in auditing EOB data from claims adjudication through disbursement, identifies defects or inconsistencies, and contributes to process improvements that enhance operational efficiency and member experience.

Responsibilities:

• Support EOB data mapping activities, including documenting data sources, data transformation rules, and output requirements.
• Analyze EOB data to ensure compliance with regulatory, business, and client-specific requirements.
• Identify and document defects, data gaps, or mapping issues and work with technical and operational teams to resolve them.
• Conduct audits of EOB output from claim adjudication through disbursement to validate data accuracy and display integrity.
• Perform root-cause analysis for EOB-related audit findings and contribute to corrective action plans.
• Assist with ongoing monitoring to track improvements and ensure audit standards are sustained.
• Support project teams in gathering business requirements for EOB enhancements, new product implementations, and regulatory updates.
• Prepare and maintain project-related reports and documentation to ensure transparency for business partners and leadership.
• Collaborate with operations leadership to refine requirements and provide data-driven insights for decision-making.
• Translate EOB and claim data into trends, patterns, and projections to support operational performance assessments.
• Assist in modeling the impact of operational scenarios (e.g., claim volume, provider behavior, member utilization) on EOB outputs and workflows.
• Identify opportunities to streamline EOB processes, enhance data quality, and improve audit accuracy.
• Provide recommendations for system or process improvements based on data analysis and audit trends.
• Partner with claims operations, BTS, performance auditing, and client leadership to ensure EOB needs are met across the organization.
• Support the development of self‑funded group EOBs to align with group specifications and member experience standards.

Requirements:

• Background in Business, Data Analytics, Information Systems, Healthcare Administration, or related field, or equivalent work experience required.
• 2+ years of experience in claims processing, healthcare operations, business analysis, or data validation.
• Strong analytical and problem‑solving skills with high attention to detail.
• Effective communication skills with the ability to translate complex data for non-technical stakeholders.
• Proficiency in data analysis tools required.
• Ability to interpret and document business and technical requirements.