The Membership & Eligibility Representative is responsible for the daily operations of both Eligibility and Membership Department. Provides Alignment Health Plan (AHP) internal departments, employee/partners and contracted providers in obtaining proper eligibility and membership data.
Essential Duties and Responsibilities
Essential duties and responsibilities include but are not limited to:
- Responsible for the reconciliation of all lines of business, as well as the CMS monthly files.
- Responsible to assist within both areas of membership and eligibility. This includes late enrollment penalty, disenrollments, out of areas, retros, third party submissions etc.
- Updating and deleting members other coverage through COB contractor via ECRS.
- Ensure members file is flagged with the proper coverage. (primary or secondary)
- Ensure all COB data is transferred into EZ-Cap.
- Responsible for surveying current members with other coverage on a yearly basis as well as new members.
- Collaborate with I.T. on creating reports and any system updates as per CMS guidelines.
- Responsible for meeting the regulatory compliance in all areas that affect the Eligibility and Membership.
- Answers the incoming phone calls within the goal marks set. Responsible for the daily, weekly, and monthly review and reporting of departmental queue stat reports to include Wrap-Up Code Reports, Resolution Contact Reports, and Agent Availability Reports.
- Ongoing clean-up of member data in all lines of business to ensure correct member information is provided to all systems and vendors.
- Meet specific deadlines. Responds to variations in daily workload by assigning task priorities according to department policies and standards.
- Ensure daily TRR is validated and all transactions are reviewed.
- Problem-solving process to resolve and/or mitigate those operational issues resulting in negative performance to plan as determined by the established escalation process.
- Will ensure that participation is made in the development and implementation of programs with direct effect towards the eligibility department. Participate in training programs and with the creation of materials for the day-to-day activity that is performed within the department.
- Will assist with creating department policies and procedures as needed to ensure the department is in accordance with CMS guidelines.
- Ensure all files are maintained in the shared drive.
- Submit monthly productivity reports to the Director.
- Assists with creating and implementing systems to improve workflows, tracking, reporting, and maintenance.
- Performs other duties as assigned.
There are no supervisory responsibilities.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- High school diploma required; BA preferred
- Minimum 2-5 years in a Health Maintenance Organization HMO or Medicare Advantage Prescription Drug Plan( MA-PD) preferred
- Must be familiar with CMS MMR and TRR files
- Chapter 2 Manage Care
- Strong sense of excellent customer service
- Strong written communication skills
- Proficient data entry skills
- Proficiency with Microsoft Office (Word, Excel, Access)
- Ability to complete tasks in a timely manner
- Strong organizational skills
- Ability to communicate effectively
- Good organizational skills
- Ability to prioritize
- Self-starter and able to work independently
- Excellent problem solving skills
Skills and Abilities
- Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
- Mathematical Skills: Ability to add and subtract two digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Strong computer skills.
- Other Skills and Abilities:
- Strong organizational skills.
- Good telecommunications skills.
Attention to detail a must.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to walk; stand; reach with hands and arms.
- The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.