Eligibility and Enrollment Specialist
About The Position
The Eligibility and Enrollment Specialist supports contracted partners, community members, providers, and managed care organizations throughout the eligibility process. The role answers questions and ensures accurate information about eligibility and prior authorization requirements to support timely service delivery. With a detailed understanding of program requirements and compassionate communication, the specialist connects health-related social needs (HRSN) providers with the people they serve. The specialist is the primary contact for enrollment, eligibility, and prior authorization matters; verifies Medicaid eligibility; maintains accurate records; coordinates changes and discrepancy resolution with internal teams and external organizations; and supports eligibility determinations and prior authorizations for designated HRSN services. The role also supports compliance reviews, service reconsiderations, and appeals, and escalates potential compliance risks. The position may involve access to protected health information and requires compliance with company policies and applicable HIPAA regulations.
Requirements
- High school diploma or equivalent.
- Ability to interpret and operationalize federal, state, and local guidelines, including NYSDOH guidelines for HRSN service management.
- Strong working knowledge of program eligibility criteria and the ability to apply criteria to enrollment and eligibility determinations.
- Knowledge of policy changes and updates to support accurate eligibility determinations and program integrity.
- Ability to manage a high-volume workload, review complex cases, and make decisions based on eligibility criteria.
- Effective questioning and active listening to gather information needed to determine program eligibility.
- Strong customer service, critical-thinking, decision-making, communication, and documentation skills.
- Ability to handle sensitive and challenging conversations with care and professionalism.
- Ability to multitask, prioritize work, perform data entry, and maintain attention to detail.
- Ability to contribute individually to key performance metrics.
- Ability to work effectively in a hybrid environment involving primarily remote work and some office-based time.
- Experience with Microsoft Office Suite, including Word, Excel, PowerPoint, and Outlook, and with Zoom and/or Teams.
Nice To Haves
- Postsecondary education in Social Work, Human Services, Public Health, Healthcare Administration, or a related field.
- Relevant coursework in communication, data management, and policy analysis.
- Experience with Managed Care Organizations (MCOs) and/or case management.
- Familiarity with social services, public benefits, or healthcare programs.
- Equivalent combination of education and experience will be considered.
Responsibilities
- Serve as the primary point of contact for internal teams, network providers, MCOs, Medicaid Members, and other external stakeholders regarding enrollment, eligibility, and prior authorization.
- Handle enrollment and eligibility calls and emails, answer questions, resolve problems, and facilitate access to care for eligible Medicaid Members and their care teams.
- Verify Medicaid Member enrollment and eligibility through NYSDOH’s MEVS and/or ePACES, support screening, navigation, and enhanced HRSN services, and assign Members to an established care team provider.
- Verify and reconcile enrollment and eligibility file data, maintaining accurate records and identifying and resolving discrepancies.
- Liaise between internal departments, including Operations and Finance, and MCOs to ensure eligibility discrepancies are updated.
- Manage enrollment and eligibility changes and communicate updates to Social Care Navigators, enhanced HRSN service providers, MCOs, and other SCNs to support care access and transitions of care.
- Determine eligibility for HRSN services using established NYSDOH criteria and manage required prior authorizations for designated enhanced HRSN services according to NYSDOH guidelines and SCN workflows.
- Monitor enrollment and eligibility data and assign unassigned or disengaged community members for screening outreach.
- Maintain current documentation of enrollment, eligibility, and prior authorization information needed before HRSN services are provided.
- Support the Compliance team’s review and management of service authorizations, post-service/pre-payment reviews, and appeals or service reconsiderations from Members denied assistance.
- Escalate potential compliance risks to Performance Management and/or the VP of Compliance and Privacy, as appropriate.
- Perform work in accordance with Healthy Alliance core competencies and values and comply with policies governing protected health information.
Benefits
- Competitive compensation package.
- Medical, dental, and vision insurance, group short-term disability insurance, life insurance with buy-up options, flexible spending accounts, and company-contributed HSA accounts.
- 401(k) with company match.
- Unlimited paid time off after 90 days of employment.
- Company-sponsored training and certification opportunities.
- Hybrid work environment and people-first workplace.
- Amenities, professional development opportunities, events, and programming.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
