Eligibility Consultant

CVS Health

1d•$17 - $34

About The Position

Under general supervision, the Eligibility Consultant verifies enrollment status, updates member and client records, and responds to enrollment questions and concerns. The role maintains enrollment databases and coordinates electronic transfers of eligibility data. It researches and resolves eligibility issues involving member-specific information, working with clients, field marketing offices, and local claims operations to achieve positive service outcomes. The consultant applies technical requirements, legislative and regulatory policies, account structures, and benefit parameters when handling eligibility matters. The role develops tools and provides coding supplements, tape specifications, and error listings to clients and vendors. It serves as a liaison among clients, vendors, and IT to define business requirements for non-standard reporting, identify possible solutions, and approve programming specifications for testing non-standard arrangements. The position ensures transactions interface with downstream systems, tests and validates data files for new and existing clients using system tools, and tracks results to prevent problems and address ongoing service issues. It partners with other functions to coordinate the release of eligibility, plan structure, and benefit information; sets up policy and eligibility screens to activate plan-benefit processing; and codes system screens, policies, and structures to support downstream processes and the production and release of member and plan sponsor materials, such as ID cards. The consultant ensures legislative and compliance requirements are followed for plan sponsor and member activity, uses and interprets online resources to understand account structures and benefits, and may help develop those resources. The role determines and communicates standard service charges for electronic eligibility activities and may negotiate and communicate charges for non-standard services. Communications involving sensitive member data must comply with HIPAA requirements.

Requirements

At least 1 year of customer service experience, with the ability to communicate effectively with internal and external customers.
At least 1 year of data entry experience.
Ability to type at least 35 words per minute.
Excellent verbal and written communication skills, including articulation, spelling, grammar, proofreading, and telephone skills.
Experience with Word and proficiency in Excel.
High school diploma or GED.

Nice To Haves

Basic knowledge of the health insurance industry.
At least 6 months of experience with QuickBase.

Responsibilities

Verify enrollment status and make changes to member and client records; address enrollment questions and concerns.
Maintain enrollment databases and coordinate electronic transfers of eligibility data.
Research and resolve eligibility and enrollment issues involving member-specific information, working with clients, field marketing offices, and local claims operations.
Apply technical requirements, legislative and regulatory policies, account structures, and benefit parameters when addressing eligibility matters.
Develop tools and provide coding supplements, tape specifications, and error listings to clients and vendors.
Liaise with clients, vendors, and IT to define business requirements for non-standard reporting, identify solutions, and approve programming specifications for testing.
Ensure transactions interface with downstream systems; test and validate client data files using system tools and track results.
Coordinate with other functions to release eligibility, plan structure, and benefit information.
Set up policy and eligibility screens to activate plan-benefit processing.
Code system screens, policies, and structures to support downstream processes and the generation and release of member and plan sponsor materials, such as ID cards.
Ensure legislative and compliance requirements are followed for plan sponsor and member activity.
Use and interpret online resources to understand customer account structures and benefits; assist with developing resources as needed.
Determine and communicate standard service charges for electronic eligibility activities and, when applicable, negotiate and communicate charges for non-standard services.
Ensure communications with clients, third-party administrators, and brokers involving sensitive member data comply with HIPAA requirements.