- Audits performance (accuracy and production) of all external organizations delegated to perform eligibility functions; communicates any required data updates to those organizations in a timely fashion.
- Audits all received enrollment forms and enrollment data entered online by brokers, employer human resources departments, and individuals for accuracy and completeness; drafts communiqués with external entities to resolve any questions.
- Processes updates to member eligibility and demographics per information from brokers, employer human resources departments, management, enrollees, other departments, etc., and ensures that requisite documentation is maintained within the document management system.
- Addresses broker, client, and individual questions related to eligibility issues in a timely fashion; monitors departmental e-mail in-boxes, faxes, telephones, and work queues and responds to inquiries and requests accordingly; works to resolve eligibility issues raised by other departments; assists in the enrollment process by documenting and logging enrollment issues.
- Collaborates with management in the preparation of departmental daily and monthly operational and production reports as required.
- Assists management with oversight of eligibility reconciliations and the capture of appropriate documentation supporting any updates to system eligibility records; coordinates the preparation of enrollment files and tracking of enrollment activities.
- Functions as a liaison between department and enrollment vendors.
- Monitors inventory levels of departmental workload and observes departmental policies and workflows to always ensure maximum production.
- Collaborates with management in the development and maintenance of departmental policies and procedures and desktop procedures according to current business needs as well as industry and regulatory requirements; assists management with the preparation of training materials and presentation of in-services as requested.
- Communicates, collaborates, and cooperates with internal and external stakeholders in a respectful and responsible manner to enhance relationships and render exceptional service.
- Adheres to all Compliance/Program Integrity requirements.
- Complies with HIPAA Regulations.
- Performs other duties as assigned.
- Two (2) years' experience in healthcare planning/operations or business operations focused on health plan eligibility, enrollment record maintenance, or another health plan member services area.
- Five (5) years of experience in managed care or healthcare customer service, eligibility, finance, or member services; commercial and Medicare experience preferred
- Knowledgeable of and compliant with all relevant laws, rules, regulations and accreditation standards and requirements regarding health plan enrollment operations (ERISA, Department of Labor, HIPAA, Texas Department of Insurance, Centers for Medicare and Medicaid Services, etc.)
- Strong knowledge of provider network arrangements and their relation to eligibility
- Strong understanding of benefit plan design and benefit plan structures such as utilization counters and their relation to eligibility
- Strong working knowledge of CMS enrollment regulations and requirements
- Proficient with Microsoft Access, Excel and Word
- Ability to identify training opportunities within assigned team or mentoring needs of individuals coupled with the necessary communication skills to provide the training
- Ability to interact with various external entities such as health care providers, regulators, employer Human Resources Departments, clients, brokers, and members, etc
- Excellent verbal, written and communications skills
- Ability to perform cross-functionally in a matrix environment as workplace demands require collaboration and assistance between departmental functions
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Health Plan Enrollment Specialist - Houston, United States - Apex Health Solutions
Description
Job Description
Job DescriptionSummaryThe Commercial Health Plan Enrollment Specialist is responsible for maintenance of eligibility data, resolving all issues or requests regarding eligibility, facilitating enrollment of potential members, and rendering any needed system updates. Will collaborate in analyzing issues that impact and affect the Eligibility Department's processes and procedures and provide feedback and recommendations.
Essential Functions include the following. Other duties may be assigned.
Education
Associate degree in business management or related field preferred.
Experience
Skills
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