The Eligibility Representative is responsible for the day-to-day operations regarding member eligibility and PCP assignment. As well as provide support to internal departments, employee/partner and contracted providers in obtaining proper member, PCP, and eligibility information. Ensure that all member discrepancies are corrected within database.
Essential Duties and Responsibilities
Essential duties and responsibilities include, but are not limited to:
Responsible for assisting the department with month-end eligibility process. This includes ensuring that each member has a PCP assignment, updating all new and terminated members and the processing and distribution of PCP and specialty E-lists.
Provide proper member eligibility to vendors, providers and outside agencies.
Ongoing cleanup of member data to ensure correct member information as well as ensure that the internal provider and specialty cross reference table is maintained up to date within the required data base systems.
Ensure that all requests for regular and retro PCP transfers as completed by the Member Services Staff or Network Operations are completed and report all changes on a monthly basis to providers via the PCP Elist, as well as daily updates to the necessary agencies.
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.
Meet specific deadlines. Responds to variations in daily workload by assigning task priorities according to department policies and standards.
Prepares source data for computer entry by compiling and sorting information; establishing entry priorities.
Maintains data entry requirements by following data program techniques and procedures.
Enters customer and account data by inputting alphabetic and numeric information on keyboard or optical scanner according to screen format.
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.
Education and/or Experience: High school diploma or general education degree (GED) preferred but not required; or at least six months related experience and/or training; or equivalent combination of education and experience
Certificates, Licenses, Registrations: None required.
Other Qualifications: Previous experience in similar position
- 1-2 years of HMO experience
- Experience in Excel and Word
- 2 experience years of Data Entry
- 2 years general office background
- 1 –2 years of Customer Service experience
- Must speak fluently in Spanish
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: Basic skills required.
Other Skills and Abilities:
Good organizational skills.
Ability to reason and carry out instructions.
Good interpersonal skills.
Ability to type 45+ words per minute.
Strong Customer Services skills.
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 reach with hands and arms.
The employee is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl.
The employee must occasionally lift and/or move up to 30 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.