Job Description:

Healthcare Domain - Member enrollment & eligibility — X12 834 maintenance, retro adjustments, deeming, 820 premium linkage, reconciliation across Medicaid/MA/Duals/MMP/TRICARE/Marketplace

Core Skills Needed - Facets (REQUIRED), X12 EDI (834, 820, 270/271), SQL, TOSCA, ADO, enrollment reconciliation

Core technical & domain requirements:
Facets — REQUIRED: membership/enrollment module testing, subscriber/member configuration, and 834-to-Facets data flow validation
X12 EDI: 834 (Perk Enrollment & Maintenance) — full transaction expertise
Member add/change/term, dependent handling, dual-enrollment scenarios
Retroactive adjustments and deeming logic (Medicaid/MMP/Dual)
820 (Premium Payment) validation linkage
Member eligibility cross-validation (270/271 correlation)
Enrollment reconciliation: source system vs.



downstream (enrollment DB ↔ claims ↔ eligibility)
SQL for member-level data comparisons (effective dates, plan codes, LOB flags)
TOSCA or similar automation tool
LOB knowledge: Medicaid, Medicare Advantage, Duals/MMP, TRICARE, Marketplace

Responsibilities:
Design enrollment scenarios including retro, term, and dual-enrollment.
Build/maintain automation; lead 820 linkage and 270/271 correlation testing.
Lead reconciliation between 834 source and downstream member records.
Own offshore enrollment test design across LOBs and deeming logic.
Drive automation coverage and mentor analysts.
Conduct RCA on eligibility and reconciliation discrepancies.

📌 Sdet Engineer Member Enrollment & Eligibility Pune
🏢 r3 Consultant
📍 Pune