Elig & Enrollment Specialist
About The Position
The Eligibility and Enrollment Specialist is responsible for receiving, reviewing, processing, and maintaining new member(s) enrollment information. This role ensures that member eligibility and enrollment requirements/verifications comply with Health Human Services Commission (HHSC) contractual requirements and Utilization Review Accreditation Commission (URAC) standards. The position involves performing a range of assigned tasks, from routine error corrections and data management to more complex analysis, reporting, and process definition, depending on the level (Specialist I, Specialist II, or Analyst). Individuals in these roles are expected to exercise discretion and independent judgment within established procedures, respond to member eligibility questions, validate information, manage escalations, and maintain high volumes of eligibility and enrollment matters while meeting set metrics.
Requirements
- Two-year degree or Associate’s degree; or 1 year related experience and/or training with High School Diploma; or equivalent combination of education and experience (for Specialist I)
- Experience with Microsoft Excel and Word (for Specialist I)
- Experience with health insurance and managed care principles (for Specialist I)
- Ability to work independently, or in a team environment, toward meeting common goals (for Specialist I)
- Integrity and discretion to maintain confidentiality of member and provider data (for Specialist I)
- Ability to apply concepts of eligibility and enrollment following established procedures and workflows for completion of assigned tasks (for Specialist I)
- Ability to multi-task and meet deadlines in a fast-paced environment (for Specialist I)
- Two-year degree or Associate’s degree; minimum 5 years of related experience and/ or training with High School Diploma; or equivalent combination of education and experience (for Specialist II)
- Proficiency with Microsoft Excel and Word (for Specialist II)
- Advanced experience with health insurance and managed care principles (for Specialist II)
- Experience with insurance eligibility and enrollment concepts (for Specialist II)
- Advanced analytical skills with ability to collect, organize, analyze and disseminate and communicate information with attention to detail and accuracy (for Specialist II)
- Ability to access data in varied formats with different methods of analyzing and processing (for Specialist II)
Responsibilities
- Maintains utmost level of confidentiality at all times
- Adheres to Health System and Health Plan policies and procedures
- Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines
- Performs all other tasks as assigned by upper management
- Adheres to department policies, procedures and guidelines
- Monthly File Error Correction
- Daily Enrollment Error Correction
- PCP Assignment
- Coverage Creation
- CRM Resolution
- Correcting Pharmacy Issues
- Pharmacy Member Creation
- Newborn Creation
- Newborn Research/ Matching
- Analyzing Newborn data and reconciling it against Claims information
- 2nd Level HHSC E&E Escalation inquiries
- Member data merges
- E&E Monthly, Weekly, Daily Reporting
- Mentorship of Level I and II E&E Specialists
- Defining Processes for E&E workflows
- Data Analysis of E&E Trends
- State Metric Reporting
- DCH/DHS Coordination for data discrepancies
- DHS Interdepartmental Process Improvement/Coordination
- Quarterly Upgrade UAT Testing and analysis
- Responsible for receiving, reviewing, processing, and maintaining new member(s) enrollment information
- Responds to member eligibility questions and verifies enrollment status as required
- Reviews enrollment/eligibility submissions to identify any missing data and to validate information provided; reconcile any discrepancies
- Submits files to relevant internal teams; provide any updates/changes/additions to enrollment/eligibility segments as needed to meet deadline requirements
- Escalates eligibility and enrollments matters to Maximus and HHSC when required and manages timely resolution of escalations
- Responsible for answering, verifying and reporting high-volumes of eligibility and enrollment matters
- Ensures that eligibility and enrollment metrics set by Management are met
- Maintains compliance with HHSC contractual requirements and URAC standards
- Generates reports that track trends and changes over time
- Understands written communications from Manager concerning the necessary operations of the department and changes that may need to be implemented
- Maintains productive, timely and effective communication with co-workers and Manager about eligibility and enrollment and departmental issues
- Assists with member PCP assignments and updates as needed
- Assists with newborn enrollment until Medicaid approval is verified
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
Number of Employees
501-1,000 employees
