We enjoy the important work we do every day on behalf of our members.
Job Summary
Remote Role but must reside in one of the following approved states: MA, RI, NH, CT
Under Direction of the Manager, oversee the team that performs analytical functions, problem resolution, reporting, develop Business Requirements and perform UAT. Additional duties include identifying system issues, reviewing functional specifications, recommending systems enhancements, and developing and validating test plans for changes to all Enrollment and EDI systems and administrative platforms.
Job Description
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS*Implementations
- Oversee the implementation and testing process for each new vendor/employer group interested in utilizing the EDI enrollment process.
- Ensure customer implementation meetings are properly facilitated for activities with customer representative and IS, ensuring that all action items are clearly delegated and completed.
- Ensure changes/enhancements are launched into production on time and then properly transitioned to the department with documentation and training.
Production Systems Maintenance & Enhancements (Following duties apply to all EDI and enrollment systems)
- Maintain a solid and thorough understanding of the Enrollment and EDI systems and Tufts HP eligibility policies/rules by line of business to identify system problems and develop recommendations for solutions.
- Analyze error reports and trends to determine when service requests are necessary.
- Act as the subject matter expert to develop all necessary business requirements for service requests, corporate initiatives and/or department-sponsored enhancements that require updates to any Enrollment/EDI system.
- Create and validate test plans for system changes and analyze actual results to determine if logic changes meet established requirements or require additional modification.
Daily Production Support
- Oversee daily production and maintenance of EDI enrollment files and provide additional assistance to staff during high volume, open enrollment periods.
- Respond to escalated and complex issues timely and accurately by using all available resources including partner departments.
Team Organization and Staff Development
- Schedule and delegate all tasks and special projects
- Interview, hire, and ensure training of new staff on all aspects of the EDI enrollment process.
- Mentor, motivate, and develop staff to obtain maximum performance; address individual performance issues in a timely and effective manner.
- Write annual performance appraisals and salary reviews
- Facilitate regular staff meetings to share knowledge of new processes, procedures, and corporate directives and solicit recommendations for continuous improvement.
- Meet on a regular basis with each report on an individual level to provide focused feedback, career direction, discuss specific concerns or ideas and/or other issues as they arise.
Additional Duties
- Maintain thorough knowledge of HIPAA standards and regulations for 834 Benefit Enrollment & Maintenance transactions.
- Project manage changes required to EDI systems to remain compliant with HIPAA regulations.
- Provide back-up support, as requested, for other areas within the department.
- Special projects as requested by management
Requirements
Qualifications (Minimum education & experience level required):Bachelor’s degree, preferably in Business Administration, with 5 – 8 years work experience in operations required. Prior health care experience preferred.Ideal candidate is familiar with working in a legacy/mainframe business environment and has extensive knowledge of the TPA eligibility EDI process and/or implementation experience with the 834 Benefit Enrollment & Maintenance transaction (HIPAA Standard).
- Intermediate knowledge of SQL and MS Office applications (specifically Excel, Word, and Access) required.
Skill requirements (include complexity of position):Requires excellent organizational, problem solving and analytical skills. Excellent judgment and decision-making ability must be displayed at all times. Interpersonal skills (include personal interaction):Requires the ability to effectively and diplomatically deal with sensitive issues. Must be able to work independently and cooperatively as a team member. Must be able to communicate effectively with internal and external customers in verbal and written format. Must display a professional demeanor at all times.Confidential data:All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material. Must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.Working Conditions or Additional requirements (include special requirements, e.g., lifting, travel, overtime)Must be able to be flexible to travel to customer sites, have a valid Massachusetts driver’s license and reliable automobile. Must be able to work non-standard hours whenever necessary, including but not limited to evenings and weekend hours.
What we build together changes our customer’s health for the better. We are looking for talented and innovative people to join our team. Come join us!
Tufts Health Plan is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here. If you’d like more information on your EEO rights under the law, please click here.