Eligibility and Enrollment Specialist

Healthy Alliance • City of Schenectady, NY

5d • Hybrid

About The Position

The Eligibility and Enrollment Specialist provides support to contracted partners, community members, providers, and managed care organizations (MCOs) throughout the eligibility process by answering questions and ensuring accurate information regarding eligibility and prior authorization requirements for timely service delivery. Through detailed understanding of program requirements and compassionate interaction with community members and their care team, this position will serve as a crucial link between health-related social need (HRSN) providers and the people they are designed to assist.

Requirements

• Relevant education and experience in areas of study including social or clinical work, health or social care program administration.
• Coursework in communication, data management, and policy analysis is preferred.
• Managed Care and Case Management experience preferred.
• Experience dissecting legal and procedural documents to ensure assessments are accurate and in line with current policies.
• Experience working with community members and care teams to determine eligibility and collaborating with care teams to obtain prior authorization for programs and services.
• Experience applying federal, state, and local regulations to evaluate applications for HRSN services.
• In-depth knowledge of guidelines across federal, state, and local levels and ability to interpret and operationalize NYSDOH guidelines for management of HRSN services.
• Strong working knowledge of program eligibility criteria for successful enrollment of HRSN services.
• Demonstrated knowledge of policy changes and updates for accurate eligibility determination and program integrity maintenance.
• Ability to manage high-volume workload, review complex cases, and make decisions based on eligibility criteria
• Familiarity with social services or benefits administration.
• Effective questioning and active listening to gather crucial applicant information to determine program eligibility.
• Strong experience and demonstrated excellence in customer service.
• Ability to handle sensitive conversations with care, making applicants and care teams feel respected and understood.
• Strong critical thinking, decision making, and communication skills.
• Strong documentation skills.
• Ability to contribute individually to the success of key performance metrics.
• Ability to successfully manage challenging conversations.
• Ability to multi-task and prioritize work, data entry, and attention to detail. Ability to effectively work in a hybrid environment that requires primarily remote work with some office-based time.
• Experience with MS Office Suite, including Word, Excel, PowerPoint, Outlook, and Zoom/Teams.
• Perform all work in accordance with Healthy Alliance core competencies and values.

Responsibilities

• Serve as the primary point of contact for internal teams, network providers, MCOs, Medicaid Members, and other external stakeholders for all enrollment, eligibility, and prior authorization activities and needs.
• Handle enrollment and eligibility phone calls and emails to answer questions, solve problems, and facilitate access to care for eligible Medicaid Members and their care teams.
• Validate Medicaid Member enrollment and eligibility through New York State Department of Health’s (NYSDOH) Medicaid Eligibility Verification System (MEVS) and/or Electronic Provider Assisted Claim Entry System (ePACES) to support screening, navigation, and enhanced HRSN services and assign Members to an established care team provider.
• Ensure accurate enrollment and eligibility records through proactive verification and reconciliation of enrollment and eligibility file data, including identifying and resolving discrepancies.
• Serve as the primary liaison between internal departments, including Operations and Finance, and MCOs to ensure eligibility discrepancies are updated.
• Manage changes to enrollment and eligibility, documenting and communicating updates to Social Care Navigators, enhanced HRSN service providers, MCOs, and other SCNs to support care access and transitions of care.
• Facilitate eligibility determinations for HRSN services based on established NYSDOH eligibility criteria. Manage SCN-required prior authorizations for designated enhanced HRSN services as per NYSDOH guidelines and SCN workflows.
• Proactively monitor enrollment and eligibility data to assign unassigned and/or disengaged community members for screening outreach.
• Maintain accurate and up-to-date documentation of enrollment, eligibility, and prior authorization information needed in advance of HRSN service provision.
• Support the Compliance team’s review and management of service authorizations, post-service/pre-payment reviews and appeal/service reconsiderations from Medicaid Members who have been denied assistance.
• Escalate any potential compliance risks as appropriate to Performance Management and/or VP of Compliance and Privacy.

Benefits

• Competitive compensation package
• Comprehensive insurance benefits available the 1st of the month after hire, including but not limited to medical, dental and vision, group short-term disability and life insurance with buy-up options, flexible spending and HSA company-contributed accounts, and more
• 401K with a company match
• Unlimited paid time off after 90 days of employment
• Company-sponsored training and certification opportunities
• Hybrid work environment and people-first workplace
• A workplace that values safety, respect, employee engagement, recognition, and diversity

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed