Business yst - HealthRules Enrollment
Business yst - HealthRules Enrollment
Posted on :
12-09-2024
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Job Description
We are seeking a Health Plan Subject Matter Expert (SME) specializing in Enrollment processes and EDI 834 transactions. The ideal candidate will have a deep understanding of health plan operations enrollment and eligibility processing and expertise in managing Electronic Data Interchange (EDI) systems. The SME will be responsible for overseeing the enrollment lifecycle ensuring compliance with HIPAA regulations and optimizing EDI transaction processes.
Key Responsibilities:
Enrollment & Eligibility Processing:
Lead the design development and implementation of enrollment and eligibility solutions for health plan systems.
Manage endtoend enrollment processes including initial submission maintenance and terminations.
Ensure compliance with federal state and payerspecific enrollment guidelines.
Work with internal and external stakeholders to resolve complex enrollment issues.
EDI 834 Management:
Manage endtoend enrollment processes including initial submission maintenance and terminations.
Ensure compliance with federal state and payerspecific enrollment guidelines.
Work with internal and external stakeholders to resolve complex enrollment issues.
EDI 834 Management:
Manage the implementation testing and maintenance of EDI 834 files for enrollment.
Collaborate with payers providers and vendors to ensure accurate and timely exchange of EDI 834 transactions.
Analyze map and troubleshoot inbound and outbound 834 transactions to ensure data integrity.
Develop and implement best practices for 834 processing and reporting.
Compliance & Regulatory Support:
Collaborate with payers providers and vendors to ensure accurate and timely exchange of EDI 834 transactions.
Analyze map and troubleshoot inbound and outbound 834 transactions to ensure data integrity.
Develop and implement best practices for 834 processing and reporting.
Compliance & Regulatory Support:
Ensure all enrollment and EDI transactions comply with HIPAA and other regulatory standards.
Stay uptodate with changes in EDI standards CMS guidelines and other regulatory requirements.
Collaborate with compliance teams to audit enrollment data and processes for accuracy.
Process Improvement:
Stay uptodate with changes in EDI standards CMS guidelines and other regulatory requirements.
Collaborate with compliance teams to audit enrollment data and processes for accuracy.
Process Improvement:
Identify areas for operational improvements and develop plans to streamline enrollment and EDI processes.
Utilize data analytics and reporting to track enrollment metrics and improve service delivery.
Participate in system upgrades and enhancements related to enrollment and EDI functions.
Collaboration & Stakeholder Management:
Utilize data analytics and reporting to track enrollment metrics and improve service delivery.
Participate in system upgrades and enhancements related to enrollment and EDI functions.
Collaboration & Stakeholder Management:
Serve as a subject matter expert for internal teams on enrollment and EDIrelated inquiries.
Work closely with IT compliance customer service and external partners to ensure smooth coordination and execution of enrollment activities.
Provide training and support to team members on EDI 834 and enrollment processes.
Qualifications:
Work closely with IT compliance customer service and external partners to ensure smooth coordination and execution of enrollment activities.
Provide training and support to team members on EDI 834 and enrollment processes.
Qualifications:
Bachelors degree in Healthcare Information Technology Business or related field.
5 years of experience working with health plans focusing on enrollment and eligibility processes.
Expertise in HIPAAcompliant EDI 834 transactions mapping and troubleshooting.
Strong knowledge of healthcare enrollment processes CMS guidelines and regulatory compliance.
Proficiency in EDI standards (ANSI X12) and working with EDI translation software and tools.
Excellent problemsolving analytical and communication skills.
Experience with healthcare enrollment platforms (e.g. Facets QNXT or similar systems) is a plus.
Strong organizational skills and ability to manage multiple projects simultaneously.
Preferred Skills:
5 years of experience working with health plans focusing on enrollment and eligibility processes.
Expertise in HIPAAcompliant EDI 834 transactions mapping and troubleshooting.
Strong knowledge of healthcare enrollment processes CMS guidelines and regulatory compliance.
Proficiency in EDI standards (ANSI X12) and working with EDI translation software and tools.
Excellent problemsolving analytical and communication skills.
Experience with healthcare enrollment platforms (e.g. Facets QNXT or similar systems) is a plus.
Strong organizational skills and ability to manage multiple projects simultaneously.
Preferred Skills:
Experience in project management or leading process improvement initiatives.
Familiarity with health insurance exchanges and marketplace enrollment processes.
Understanding of other EDI transaction sets (e.g.) and healthcare data formats.
Familiarity with health insurance exchanges and marketplace enrollment processes.
Understanding of other EDI transaction sets (e.g.) and healthcare data formats.
Employment Type
Full Time
Company Industry
Key Skills
- SQL
- Agile
- Business Analysis
- Visio
- Waterfall
- Business Process Modeling
- Requirements Gathering
- User Acceptance Testing
- Business requirements
- SDLC
- Systems Analysis
- Data Analysis Skills
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