SME HealthRules -Enrollment 834

Unclassified • Exton, PA

483d

About The Position

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. In this role, you will lead the design, development, and implementation of enrollment and eligibility solutions for health plan systems. You will manage end-to-end enrollment processes, including initial submission, maintenance, and terminations, while ensuring compliance with federal, state, and payer-specific enrollment guidelines. Collaboration with internal and external stakeholders will be crucial to resolve complex enrollment issues effectively. You will also manage the implementation, testing, and maintenance of EDI 834 files for enrollment, collaborating with payers, providers, and vendors to ensure accurate and timely exchange of EDI 834 transactions. Analyzing, mapping, and troubleshooting inbound and outbound 834 transactions will be part of your responsibilities to ensure data integrity. Additionally, you will develop and implement best practices for 834 processing and reporting. Compliance is a key aspect of this position, as you will ensure that all enrollment and EDI transactions comply with HIPAA and other regulatory standards. Staying up-to-date with changes in EDI standards, CMS guidelines, and other regulatory requirements will be essential. You will collaborate with compliance teams to audit enrollment data and processes for accuracy. Identifying areas for operational improvements and developing plans to streamline enrollment and EDI processes will be part of your role. Utilizing data analytics and reporting to track enrollment metrics and improve service delivery will be expected. You will also participate in system upgrades and enhancements related to enrollment and EDI functions. As a subject matter expert, you will serve as a resource for internal teams on enrollment and EDI-related inquiries. Working closely with IT, compliance, customer service, and external partners will ensure smooth coordination and execution of enrollment activities. Providing training and support to team members on EDI 834 and enrollment processes will be a key responsibility.