Gateway Specialist

Independence Blue Cross; Philadelphia, Northern (Philadelphia County, KY); Hybrid; USD 52,000 - 72,000; Full time

Job summary

Independence Blue Cross seeks an enrollment operations specialist to manage manual enrollment updates, review CMS files, and coordinate data flows through health information systems. The role requires experience with enrollment processes, EDI, and strong communication within a fast-paced healthcare environment.

Applicants should have a BA/BS in a business-related field (or equivalent) and 2–3 years of healthcare experience.

Qualifications

• Understanding of updating manual enrollment transactions in Health Rules/Proof.
• Knowledge of ACA Consumer business and CMS/Compliance regulations is a plus.
• Experience with enrollment data and CMS files (e.g., 834, 820) is beneficial.

Responsibilities

• Review outbound CMS files (834, 820, pre-audit, RCNI/Discrepancy) to improve analysis and reconciliation.
• Manage inbound/outbound electronic files via Gateway/mPulse from vendors and entities (IBX Portal, mPulse Retail, Pennie, Get Covered NJ, Edifecs).
• Analyze enrollment discrepancies and coordinate updates in mPulse or with manual enrollment team in Health Proof/CFI.
• Meet productivity and quality goals; escalate trends to management as needed.
• Participate in ad-hoc projects as required.

Skills

Enrollment systems

EDI knowledge

MS Office

Communication

Education

BA/BS in Business or equivalent

2-3 years healthcare experience

Tools

Health Rules/Proof

XML/ANSI 834 familiarity

Job description

• 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.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com . We’re revolutionizing health care, and our focus is on you!

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.