Job Overview

Job Title: Health Plan Subject Matter Expert (SME) – Enrollment & EDI 834

Job Type: Full-time | Part-time | Internship

Job Overview

We are seeking a Health Plan Subject Matter Expert (SME) specializing in Enrollment processes and EDI 834 transactions. The ideal candidate will bring extensive experience in health plan operations, enrollment and eligibility management, and Electronic Data Interchange (EDI). This position involves overseeing the enrollment lifecycle, ensuring regulatory compliance (especially HIPAA), and driving optimization of EDI processes.

Key Responsibilities

Enrollment & Eligibility Processing

• Design, develop, and implement enrollment and eligibility solutions for health plans.

• Manage complete enrollment lifecycle: submissions, maintenance, and terminations.

• Ensure compliance with federal, state, and payer-specific enrollment regulations.

• Coordinate with internal/external stakeholders to resolve complex enrollment issues.

EDI 834 Management

• Implement, test, and maintain EDI 834 files for enrollment transactions.

• Collaborate with payers, providers, and vendors to ensure timely and accurate EDI exchanges.

• Map, analyze, and troubleshoot inbound/outbound 834 transactions for data integrity.

• Develop best practices for 834 processing and reporting.

Compliance & Regulatory Support

• Ensure compliance of all enrollment and EDI transactions with HIPAA and other regulatory standards.

• Monitor and adapt to changes in EDI standards, CMS guidelines, and industry regulations.

• Conduct audits in collaboration with compliance teams to verify data accuracy.

Process Improvement

• Identify operational inefficiencies and develop plans to streamline processes.

• Utilize analytics to monitor performance metrics and enhance service delivery.

• Participate in system upgrades or enhancements involving enrollment and EDI systems.

Collaboration & Stakeholder Management

• Act as a Subject Matter Expert for enrollment and EDI inquiries.

• Collaborate with IT, compliance, customer service, and external partners to ensure seamless enrollment operations.

• Provide training and guidance on EDI 834 and enrollment procedures to internal teams.

Qualifications

Required:

• Bachelor’s degree in Healthcare, Information Technology, Business, or related field.

• 5+ years of experience with health plan operations, focusing on enrollment and eligibility.

• Deep expertise in EDI 834 transactions, including mapping and troubleshooting.

• Strong knowledge of HIPAA, CMS guidelines, and healthcare regulatory compliance.

• Familiarity with ANSI X12 standards and EDI translation tools/software.

• Excellent communication, analytical, and problem-solving skills.

Preferred:

• Experience with platforms like Facets, QNXT, or similar healthcare enrollment systems.

• Background in project management or process improvement initiatives.

• Familiarity with health insurance exchange processes and marketplace enrollments.

• Understanding of other healthcare EDI formats and transactions.

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