Gateway Specialist

Independence Blue Cross; Philadelphia (Philadelphia County); On-site; USD 55,000 - 75,000; Full time

Job summary

Independence Blue Cross is seeking a healthcare enrollment analyst to support the Commercial Membership Operations workflow in Philadelphia. You will update manual enrollment transactions, review CMS files, and manage electronic file flows through Gateways and mPulse from multiple vendors and entities.

The role emphasizes processing accuracy, adherence to production targets, and collaboration with internal teams to resolve discrepancies and improve enrollment analytics.

Qualifications

• BA/BS degree in a business-related field or equivalent experience preferred.
• 2-3 years of experience in healthcare.
• Strong knowledge of EDI/enrollment systems; familiarity with XML/ANSI 834 HIPAA X12 transactions.

Responsibilities

• Update manual enrollment transactions in Health Rules/Proof.
• Review CMS files (834, 820, pre-audit, RCNI/Discrepancy) to develop best practices.
• Manage inbound/outbound electronic files via Gateway/mPulse from vendors/government entities.
• Analyze enrollment fallout/discrepancies and triage updates to Health Proof/CFI.
• Meet productivity and quality goals; communicate trends to management.
• Perform ad-hoc projects as requested.

Skills

Healthcare enrollment knowledge

Analytical thinking

Attention to detail

Effective communication

Education

BA/BS in Business-related field

Tools

Health Rules/Proof

One Hub

SNOW

SharePoint

EDI systems

XML/ANSI 834 HIPAA X12

Job description

Responsibilities

• Have an understanding of how to update manual enrollment transactions in Health Rules/Proof.
• Have a basic understanding of ACA Consumer business and basic CMS, and Compliance Regulations.
• Review complex outbound CMS files (including 834, 820, pre-audit, and RCNI/Discrepancy files) to develop best practices for analysis, reconciliation automation, and resolution.
• 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).
• 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.
• Processes according to established productivity goals while maintaining established quality goals.
• 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.
• Work on ad-hoc projects as requested.

Education

• BA/BS Degree in a Business-related field or equivalent experience preferred.

Experience

• 2-3 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 fast-paced, 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.