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Eligibility Appeals Process SME

Remote/Hybrid if local to Maryland

Join us at Sparksoft, where we're not just another tech company—we're a catalyst for change. Our mission isn't just to offer IT solutions; it's to revolutionize the way you work. Here, passion isn't just a buzzword; it's the fuel behind groundbreaking ideas and transformative technologies. We serve a wide range of government clients, delivering impact that's felt across the nation.

Our true strength lies in our people. They're the problem-solvers and innovators consistently delivering extraordinary outcomes. With Sparksoft, you're not stepping into a routine job; you're joining a team committed to innovation and excellence. Our innovation extends beyond just delivering projects. Through our specialized Innovation Centers, we continuously refine our methods, ensuring we remain industry leaders.

We are Sparksoft!

ROLE & RESPONSIBILITIES: 

The Appeals Process Subject Matter Expert (SME) will serve as the strategic lead for business process design and optimization within the Eligibility Appeals Case Management System (EACMS). This pivotal role requires deep expertise in the end-to-end eligibility appeals lifecycle, a strong grasp of regulatory frameworks, and the ability to translate operational insights into actionable system requirements. The SME will work closely with end users, policy stakeholders, and technical teams to ensure that workflows are efficient, compliant, and centered around user needs

  • Lead the analysis and documentation of current-state appeals workflows, identifying inefficiencies, bottlenecks, and compliance risks
  • Collaborate with case workers, hearing officers, and policy experts to define future-state business processes that reflect real-world needs
  • Translate business process requirements into functional specifications for Pega development teams
  • Prioritize system enhancements and backlog items based on operational impact and regulatory alignment
  • Facilitate working sessions to validate business rules, case routing logic, and escalation paths
  • Support user acceptance testing (UAT), training, and change management for new or updated workflows
  • Ensure all process designs adhere to Affordable Care Act (ACA) guidelines, Centers for Medicare & Medicaid Services (CMS) standards, and Section 508 accessibility requirements

REQUIRED EXPERIENCE: 

  • 8+ years of experience in business process analysis or case management operations, ideally in healthcare or government programs
  • Strong understanding of ACA eligibility appeals and case resolution workflows
  • Experience working with Pega or similar case management platforms
  • Excellent facilitation, documentation, and stakeholder engagement skills
  • Familiarity with Agile methodologies and tools like JIRA, Confluence, or Mural
  • Candidates must be able to obtain and maintain a Public Trust clearance
  • Candidates must have lived in the United States 3 out of the past 5 years

PREFERRED EXPERIENCE: 

  • Prior experience and understanding of the Eligibility Appeals Case Management System (EACMS) use cases and challenges

EDUCATION & CERTIFICATIONS:

  • Bachelor’s degree in public administration, Business Process Management, Health Policy, or related field

If you need accommodation seeking employment with Sparksoft Corporation, please email Sparksoft.Accommodations@sparksoftcorp.com or call 410-424-7700. Accommodations are made on a case-by-case basis.

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