Gateway Specialist

Independence Blue Cross, LLC; Philadelphia (Philadelphia County); On-site; USD 65,000 - 85,000; Full time

Job summary

Independence Blue Cross, LLC is seeking a Healthcare Enrollment Analyst to manage complex enrollment transactions and CMS file reviews. The role focuses on optimizing data flows through Health Rules/Proof and mPulse, ensuring accurate enrollment analytics across commercial operations.

Candidates should have a BA/BS in a business field (or equivalent) and extensive healthcare experience. Proficiency with EDI/X12, CMS processes, and Microsoft tools is highly valued, with an emphasis on accuracy

Qualifications

• BA/BS degree in a business-related field or equivalent experience preferred.
• 23 years of experience in healthcare (as stated).
• Strong knowledge of enrollment processes and analytics in commercial membership operations.

Responsibilities

• Understand how to update manual enrollment transactions in Health Rules/Proof.
• Review CMS files (834, 820, preaudit, RCNI) to improve best practices and automation.
• Manage inbound/outbound electronic files via Gateway/mPulse with external entities.
• Analyze enrollment discrepancies and triage to manual enrollment when needed.
• Meet productivity and quality goals while maintaining accuracy.
• Raise awareness of trends and unusual cases with management.
• Contribute to adhoc projects as requested.

Skills

Enrollment analytics

EDI / HIPAA X12

MS Office / SharePoint

Customer communication

Detail oriented

Education

BA/BS in business-related field

Tools

Health Rules/Proof

mPulse

One Hub

SNOW / ServiceNow

SharePoint

Job description

Responsibilities

1. Have an understanding of how to update manual enrollment transactions in Health Rules/Proof.
2. Have a basic understanding of ACA Consumer business and basic CMS, and Compliance Regulations.
3. Review complex outbound CMS files (including 834, 820, preaudit, and RCNI/Discrepancy files) to develop best practices for analysis, reconciliation automation, and resolution.
4. Successfully manages the flow of inbound and outbound electronic files being received through the Gateway/mPulse from a variety of vendors or government entities (IBX Portal, mPulse Retail, Pennie, Get Covered NJ, and Edifecs).
5. Analyze enrollment fallout/discrepancies and make the appropriate update in mPulse or appropriately triage to the manual enrollment team for updates in Health Proof/CFI.
6. Processes according to established productivity goals while maintaining established quality goals.
7. Takes initiative to check and question unusual situations with management in accordance with established guidelines. Notifies the supervisor of trends that will impact internal and external customers.
8. Work on adhoc projects as requested.

Education

• BA/BS Degree in a Businessrelated field or equivalent experience preferred.

Experience

• 23 years' experience in healthcare.

Knowledge, Skills, Abilities

• Ability to work and coordinate enrollment process and analytics in Commercial Membership Operations.
• Acute knowledge of EDI & enrollment systems. Understanding of XML/ANSI 834/HIPAA X12 transactions would be beneficial but not required.
• Must possess the ability to interface with internal/external customer at various levels.
• Willingness to work in a fastpaced, challenging environment.
• Detailed oriented and organized, with exceptional prioritization skills.
• Ability to effectively communicate with others and willingness to be a team player.
• Familiarity with data processing and the ability to work with documented policies and procedures.
• Proficient in Microsoft Applications.
• Health Rules/Proof, One Hub, SNOW, SharePoint or any other system that logs productivity.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.