Eligibility Data Specialist II

Inland Empire Health Plan•Rancho Cucamonga, CA

16h•Remote

About The Position

The Eligibility Data Specialist II manage monthly and daily operations for all lines of business within the Business Systems and Transformation (BST) department. Their responsibilities encompass the processing of member eligibility, validating data, researching, fixing enrollment and eligibility systems errors, assigning members to providers, processing member materials (including ID cards), and handling interdepartmental communications and requests. They must efficiently process all tasks sent to the BST department through various communication channels including email, Events, and other interdepartmental tools. The Eligibility Specialist II must excel at documenting, analyzing, and resolving complex issues while building and maintaining effective working relationships across the organization. This position operates under general supervision but requires independent problem-solving abilities. Additionally, the Eligibility Data Specialist II will be responsible for all IEHP Covered (CCA) eligibility functions, such as CCA eligibility file processing, carrier integration testing, Research and resolve Payment Services including premium inquiries related to eligibility, respond directly to CCA inquiries, and monthly recon files. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Three (3) or more years of experience required in an HMO managed care environment in the areas of member eligibility required
Inclusive of the three (3) years minimum experience required, two (2) or more years of 834 experience are required
High School diploma or GED required
Demonstrate computer proficiency and working knowledge of Microsoft Windows and Office applications required
Intermediate spreadsheet (Excel) and database skills in Access or equivalent database manipulation preferred
Ability to work independently, under pressure, balances multiple projects and deadline driven required
Ability follow-through and track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed timely required
Ability to grasp new ideas and concepts quickly is required
Ability to successfully present ideas in an audience-oriented manner required
Ability to manage multiple projects of varying complexity, priority levels and deadlines required
Strong work ethic and highly self-motivating and directing required
Successful working in a team oriented, collaborative, and changing environment required
Willingness and ability to learn is required
Must be detail-oriented with strong organizational skills required

Nice To Haves

Experience working with Medicare/Medicaid government programs and regulatory agencies preferred
CCA experience preferred
Associate’s degree from accredited institution preferred
Understanding and knowledge of regulatory file layouts (i.e. 834)
Strong knowledge of Medicare, Medi-Cal, CCA, and NCQA regulations specific to BST responsibilities
Knowledge of Managed Care systems and client/server applications preferred
Knowledge of health plan business operations preferred

Responsibilities

Support monthly, weekly, and daily eligibility processing for all IEHP line of businesses and programs within the BST department responsibility.
Process all daily and monthly member eligibility coverage and demographic changes in the core membership system for all IEHP programs (Medi-Cal, Medicare, and CCA) accurately and within required timeframes.
Validate and confirm the completeness and accuracy of member demographic and eligibility data (address, COB coverage, eligibility status, etc.) provided by the Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS), and Covered CA in the IEHP core membership and Claims systems.
Investigate, troubleshoot, and correct member data pertaining to all lines of business identified through reports or inquiries submitted to the BST department via event queue, work baskets, or email, including running operational reports when necessary.
Identify and correct 834 eligibility errors/discrepancies resulting from system or process failures in a timely manner to maintain compliance with program guidelines. This may include reaching out to CCA hotline for research and error resolution.
Monitor regulatory file processing to identify and prevent file processing delays (i.e. 834 file).
Process and monitor member ID card files daily for all IEHP programs. Resolve fallout errors by correcting data discrepancies and reissuing ID Cards if needed.
Oversight of automated member correspondence for all lines of business, timely and accurately.
Develop and maintain a comprehensive understanding of IEHP core membership system features (i.e. 834 transactions, Premium Billing, Invoices, etc.) and interactions with downstream applications.
Contribute to Team Member engagement by participating in projects, tasks, and/or activities that promote excitement and enthusiasm for the role, increased work effort, and organizational commitment.
Incorporate LEAN principles into daily work processes.
Update member eligibility and demographic data in downstream systems, such as the Claims and Pharmacy Benefit Management system.
Assist in creating and updating desktop procedures, department job aids, and training materials for new and existing team members.
Complete User Acceptance Testing (UAT) in test environments and document findings.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.