Eligibility Dispute EDI Specialist

Join a dynamic team as an Eligibility Dispute EDI Specialist, where you will collaborate with internal teams to analyze discrepancies in the eligibility reconciliation process affecting multiple stakeholders. Your role will focus on enhancing the efficiency of the reconciliation process and ensuring accurate handling of Enrollment, Payment, UIR, and RBM casework. You'll be responsible for conducting root cause analyses, proposing solutions, and drafting comprehensive responses for complex cases related to consumer matching data and rules creation. Key Responsibilities: Innovate and devise creative solutions to meet business needs and requirements. Create and maintain comprehensive technical documentation outlining requirements and business processes. Review and ensure accuracy of training materials and policy documents. Conduct thorough review, analysis, and resolution of Enrollment, Payment, or UIR cases, achieving a monthly accuracy rate of over 95%. Serve as a subject matter expert to modernize and enhance casework user interface for improved analysis and reporting. Develop effective test cases and identify new scenarios for testing purposes. Maintain a positive attitude and act as a liaison between Enrollment Disputes, HICS Direct Disputes, and Rules development teams, providing proactive solutions and enhancements. Apply critical thinking skills to navigate complex case scenarios. Address agent broker fraud cases impacting consumers related to 1095-A or issuer disputes. Demonstrate strong multitasking abilities while maintaining flexibility to meet deadlines and support team objectives. Monitor deliverables to ensure timely case completion. Prioritize initiatives based on evolving business needs and requirements. Resolve issues promptly and accurately while escalating critical concerns as needed. Exhibit excellent verbal and written communication skills. Demonstrate high organizational skills and meticulous attention to detail. Participate in Semi-Monthly Reviews and assist with outstanding lists. Handle specific issuer requests and prepare detailed responses. Communicate effectively with team leaders and management regarding escalated casework or issuer issues. Deliver presentations clearly and engagingly. Identify and prioritize responsibilities while managing multiple tasks independently. Provide clear and concise answers for complex enrollment, payment, and UIR queries, both in writing and verbally. Collaborate effectively within a team and independently to complete all tasks efficiently. Navigating ambiguity and change while managing priorities in a dynamic environment. Additional responsibilities include: Collaborating with technical and development teams to resolve identified issues promptly. Working closely with technology teams to escalate front and backend issues. Communicating complex scenarios related to Marketplace enrollment records and reconciliation methods. Required minimum qualifications: Bachelor's Degree or equivalent OR 4 years' relevant experience in place of degree. 2 additional years of experience in the healthcare industry. Must be a US Citizen. Candidates who do not meet the required qualifications will not be considered. Preferred qualifications: 1 year of experience with X12 transactions. 1 year of experience with federal data or projects, including but not limited to agencies such as CMS, IRS, DOD, VA, SSA or another federal agency. Knowledge of the Affordable Care Act. Project management experience. Experience with Federal contracts. Experience with premium payment transactions. Experience in the reconciliation of enrollment transactions. Experience with PowerBI Reports and Dashboards. Experience with SQL queries. Compensation Ranges Compensation ranges for ASM Research positions vary depending on multiple factors, including but not limited to location, skill set, educational background, certifications, and contract-specific requirements. The compensation displayed for this role serves as a general guideline and is unique to each position. EEO Requirements ASM is committed to ensuring that employment decisions are made without regard to race, color, religion, sex, disability, age, sexual orientation, or national origin. We affirm our commitment to equal employment opportunities. Physical Requirements The physical requirements outlined in

Created: 2026-03-13