Responsible for overall web eligibility and processing of temporary EDI files. This position reviews, analyzes, and coordinates data testing for enrollment and billings changes to TAHP master for inbound and outbound eligibility files for vendors and employer groups. Additional duties include identifying system issues, writing business requirements, reviewing functional specifications, recommending systems enhancements, and developing and validating test plans for changes to all enrollment and billing systems.
System Analysis, Maintenance & Enhancements:
- Maintain a solid and thorough understanding of all the systems and policies used by the department to identify system problems and develop recommendations for solutions that support a positive customer experience.
- Analyze error reports and trends from inbound 834 enrollment files. From analysis determine when service requests or vendor change requests are necessary to minimize errors.
- Document required system fixes or enhancements to outbound or inbound eligibility files in a service request form.
- Document required fixes or enhancement requests to the vendor's web application in a change request form.
- Act as the subject matter expert to develop all necessary business requirements for service requests or change requests that require updates to any enrollment or on line billing systems.
- Assist with developing implementation plans for new on line applications as they relate to enrollment and billing.
- Create and validate test plans for enrollment and billing systems and analyze actual results to determine if logic changes meet established requirements or require additional modification.
- Monitor all enrollment/billing system revisions post implementation until production issues or enhancements are sufficiently demonstrated.
Daily Production Support:
- Generate daily reports from web vendor application to monitor all new group sales and renewals to ensure accurate group number set-up and site access for employers. Ensure all employee applications are completed timely for new business and renewals.
- Coordinate the timing and processing of group renewals in the web enrollment application ensuring data integrity of membership changes and completing enrollment reconciliations. Ensure all renewals are completed timely. Coordinate all roll-overs of membership based on timing of renewal updates to ensure ID cards are released timely.
- Respond to escalated and complex enrollment, web and EDI issues timely and accurately by using all available resources. Work with web vendor to resolve escalated issues as needed.
- Work the twice daily 834 error fall-out to resolve all enrollment transactions. Identify trends with fall-out for future enhancements to process.
- Process and control any temporary EDI files received from sales for new group set-ups. Report discrepancies to sales, control release of ID cards and store files for audit retrieval.
- Participate in meetings & teleconferences for testing activities with employer representative, sales, enrollment supervisor, and IS.
- Track and trend errors. Report monthly on findings (error types and volume).
- Track and report on SR's and vendor CR's written from analysis. And their status.
- Provide back-up support, as requested, for other areas within the department
- Special projects as requested by management
- Bachelor's degree, preferred or equivalent work experience
- 3 to 5 years work experience in operations required. Prior health care experience preferred. Ideal candidate is familiar eligibility EDI process and/or implementation experience with the 834 Benefit Enrollment & Maintenance transaction (HIPAA Standard).
- Intermediate knowledge of MS Office applications (specifically Excel, Word, and Access) preferred. Requires excellent organizational skills, problem solving and analytical skills. Excellent judgment and decision-making ability must be displayed at all times. Requires the ability to effectively and diplomatically deal with sensitive issues. Must be able to work independently and cooperatively as a team member. Must be able to communicate effectively with internal and external customers in verbal and written format. Must display a professional demeanor at all times.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
Point32Health is a leading health and wellbeing organization, delivering an ever-better health care experience to everyone in our communities. Building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
At Point32Health, we're working to reshape the world of health care by pushing past the status quo and delivering even more to the diverse communities we serve: more innovation, more access, more support, and healthier lives. And we want people like you on our side to make it even better.
This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.Req ID: R4660