SUMMARY:
The Senior Enrollment Specialist is responsible for ensuring the accuracy and timeliness of Medicare Advantage enrollment and billing transactions and processes including, late enrollment penalty, and COB, MSP, and CTM processes. This role is responsible for analyzing and evaluating enrollment and billing operational performance and processes through internal and external discussions with staff, management, and business process outsourcing vendors, as well as through reporting, quality monitoring, and oversight activities, with the expectancy of establishing and implementing process improvement initiatives that will strengthen quality and performance and lead to operational excellence and compliance.
RESPONSIBILITIES/TASKS:
* Coordinates and monitors all Medicare Advantage enrollment and billing processes including late enrollment penalty, COB and MSP functions.
* Creates and sends correspondence for and to members or designated entities.
* Monitors enrollment and billing correspondence and transactions sent to ensure accuracy and timeliness based on CMS, department, and corporate requirements.
* Assists and oversees the membership and revenue reconciliation processes including discrepancy resolution.
* Conducts outbound calls to members and other parties as required.
* Identifies and reports trends and issues identified and provides issue resolution.
* Supports and participates in system testing and requirements gathering related to operational readiness updates based on system enhancements, CMS software releases, and as needed.
* Reviews and responds to CTMs, performing a root cause and trend analysis.
* Reviews and submits audit documentation to CMS and/or its designee.
* Monitors and triages reports and correspondence including eligibility files to downstream systems, error reports, and returned correspondence.
* Provides and implements quality and process improvement initiatives and assists in the creation and implementation of policies, procedures, and workflows.
* Supports all CMS and internal audit activities as needed.
* Fosters positive working relationships with internal and external partners with open and constructive communication.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
EMPLOYMENT QUALIFICATIONS:
EDUCATION:
Bachelor's degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
EXPERIENCE:
Five years experience in a claims environment or equivalent experience which provides the necessary skills, knowledge, and abilities. Experience working in a Health Care environment or managed care is preferred.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
* Knowledge of Medicare Advantage processes and Centers for Medicare & Medicaid Services (CMS) guidelines for enrollment and billing.
* Excellent verbal and written communication skills and interpersonal skills.
* Strong analytical and critical thinking skills with a high attention to detail.
* Ability to be flexible in a fast paced environment and adaptable to change.
* Ability to work independently, as well as with all levels of staff, leadership, and external partners and vendors.
* Ability to effectively prioritize, coordinate, and lead activities.
* A strong working knowledge of Microsoft office products.
WORKING CONDITIONS:
Work is performed in an office setting with no unusual hazards. Travel is required (Approximately 20%).
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.
