Elig & Enrollment Specialist

DRISCOLL HEALTH PLAN•Corpus Christi, TX

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 are in compliance with Health Human Services Commission (HHSC) contractual requirements and Utilization Review Accreditation Commission (URAC) standards. The position operates within a compassionate, innovative, and technology-driven environment where employees are valued. Driscoll Children’s Hospital and its Health Plan serve 31 South Texas counties, focusing on advanced medical treatments and technologies for children, guided by core values of Compassion, Advocacy, Respect, Excellence, and Stewardship.

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.
Experience with Microsoft Excel and Word.
Experience with health insurance and managed care principles.
Ability to work independently, or in a team environment, toward meeting common goals.
Integrity and discretion to maintain confidentiality of member and provider data.
Ability to apply concepts of eligibility and enrollment following established procedures and workflows for completion of assigned tasks.
Ability to multi-task and meet deadlines in a fast-paced environment.
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.
Performs Monthly File Error Correction.
Performs Daily Enrollment Error Correction.
Performs PCP Assignment.
Performs Coverage Creation.
Handles CRM Resolution.
Corrects Pharmacy Issues.
Performs Pharmacy Member Creation.
Performs Newborn Creation.
Performs Newborn Research/Matching.
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.