It’s Time For A Change…
Your Future Evolves Here
Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving power that brings us to work each day. We believe in embracing new ideas, testing ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.
Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign's Corporate Equality Index, was named on the Best Companies for Women to Advance List 2020 by Parity.org, and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.
Optional: Who You’ll Be Working With:
We are looking for bright and energetic individuals to join our Business Integration (BI) team developing business processes, designing and building on requirements for new and existing clients implementations, business process support with emphasis on end to end provider data management, enrollment and eligibility, member benefits, claim adjudication and HealthCare EDI Interfaces business and technical processes.
What You’ll Be Doing:
- Define business requirements and acceptance criteria/test cases
- Define business requirements and acceptance criteria/test cases related to State Medicaid and CMS programs.
- Review regulations from State Medicaid and CMS programs.
- Utilize a variety of software and platforms for statistical analysis and research concerning data
- Create and standardize solutions and workflows.
- Perform business analysis of identified process and software gaps or inefficiencies and develop plans to fill those gaps for internal business processes and for external clients.
- Perform requirements review with external and internal stakeholders and obtain sign off from all required individuals.
- Identifies and documents system deficiencies and recommends solutions.
- Facilitation and Coordination with internal and external stakeholders including SME’s to gather requirements
- Requirements definition using the Evolent BRD template by workstream (Enrollment and Eligibility, Provider Data Management, Benefits and Claims, Interfaces)
- Obtain requirements signoff from external and internal stakeholders
- Coordination with Ops teams and training to create/update necessary P&P’s or training manuals
- Coordination with Config and IT Engineering to prepare development ready work
- Support Integration Quality team while executing the test cases/script
The Experience You’ll Need (Required):
- Extensive knowledge in health insurance third party administrator concepts for commercial, federal and state government plans specifically support operational processes for provider data management functions, enrollment and eligibility, member benefits, claims adjudication and EDI Interfaces functions.
- Knowledge of State regulations to determine provider meets qualification to be enrolled.
- Knowledge of provider files from State Medicaid programs to decipher provider enrollment and eligibility rules.
- Knowledge of provider type designation identified by the State Medicaid programs.
- Knowledge of provider and member portal functions.
- Knowledge of provider reimbursement methodologies about Commercial, CMS and State defined guidelines.
- Knowledge of provider matching criteria for claims.
- Knowledge of Coordination of Benefits (COB) and Claim Authorizations functions.
- Knowledge of Setting up communications for EDI transmissions using FTP, SFTP and real time API setups
- Knowledge of health insurance, HMO and managed care principles including Medicaid and Medicare regulation.
- Solid analytical skills with the ability to compile data from many sources and define designs for enrollment to benefit plan configuration.
- Research, interpret and summarize new state, federal and client rules regarding department functions. Alter or create policies and procedures to adhere to those rules.
- Solid communication skills with working session facilitation.
- Strong time management, attention to detail, analytic and organizational skills.
- Excellent interpersonal, oral and written communication skills.
- Able to work independently and within a collaborative team environment with little guidance/supervision.
Finishing Touches (Preferred):
- Associate or bachelor’s degree preferred.
- HMO/PPO Claims, Medicaid, Medicare and/or managed care environment preferred.
- Certified Business Analyst is strongly preferred; equivalent demonstrated business analysis experience.
- Extensive experience with the System Design Life Cycle (SDLC).
- Superior root cause analysis skills, including corrective action planning and ability to provide documentation to support analysis.