Healthcare Beneficiary Eligibility SME

Federal Requirements:  

• Ability to obtain a U.S. Federal Position of Trust clearance designation.  
• Must reside in and be able to perform work in the United States.  
• Must have lived in the United States for 3 of the last 5 years.  

Basic Qualifications:

• Bachelor’s degree in information technology, computer science or related discipline. 
• 8 or more years of experience in related positions including as a SME, policy analyst, data engineer, product analyst, product manager and other software and application development work.  
• Minimum 3-5 years of working experience working directly with HIPAA (Health Insurance Portability and Accountability Act) rules requirements for health plans, healthcare clearinghouses and healthcare providers in transmitting claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets.  
• X12 5010A1 experience with real-time applications is essential. Broad experience with a variety of X12N transactions is preferred.  
• Involvement and deep understanding of X12N (including workgroups), CAQH CORE and/or HL7 FHIR relevant to benefit eligibility is strongly preferred. 
• Experience engineering and/or implementing SOAP and/or REST connectivity for real-time eligibility transactions is highly desirable. 
• Experience with high availability, multi environment AWS implementations that process 24/7/365 highly preferable. Experience with fully redundant, high volume (billions annually) applications is highly desirable. 
• Experience working with agile teams. 

Responsibilities:

• Attend and participate in standards/sanctioning workgroups across the healthcare EDI industry. Actively participate in development of these standards with an eye towards representing federal government interests. Provide guidance and feedback to business stakeholders regarding key standards initiatives.  
• Perform impact assessments on upcoming standard changes, in identifying necessary changes to the program and work within the team and stakeholders to implement timely modifications to the system. 
• Identify and communicate changes to the EDI 270/271 transactions to prepare end user and various stakeholders on upcoming standard changes. 
• As a Federal initiative identify ways to securely improve medical provider information, expedite the claims processing cycle and preserve the Medicare endowment. Applicants must work with various stakeholders to actively protect beneficiary information, in exceeding federal security. 
• Evaluates business processes and operations by implementing subject expertise, identifies problem areas, and provides relevant business solutions. 
• Offers guidance and required knowledge to product teams during the software development life cycle.  
• Analyze eligibility/benefits inquiry to identify trends and gaps to the EDI 270/271transaction. 
• Offer consulting services, contribute to specialized knowledge, and provide mentorship and training to teams. 
• Verifies business and technical information, including the training manuals, user guides, and system requirements.  
• Publicize important information and documents processes to stakeholders. 
• Performs hands-on basic data query and exploratory analysis work and/or guides others in needed data analysis and interprets findings. 

Benefits and Perks:

• 65%-75% company-sponsored (including dependents) premiums for medical, dental and vision insurance. For eligible plans and tiers, we provide 100% company-paid medical insurance. 100% employer sponsored STD, LTD and life insurance (min $100K). Voluntary life insurance option available.
• Retirement 401(k) plan with employer matching. Immediate vesting. 
• Vacation and sick leave. 
• Maternity and parental leave.  
• Discretionary bonuses, spot awards, gifts, and tenure-based rewards. 
• Company-sponsored role-based training and certifications.  
• Monthly Doordash DashPass subscription. 
• Group discounts via LifeMart ADP