Enrollment/Disenrollment Specialist (Bilingual - Spanish, Tagalog, or Chinese)

Health Plan of San Mateo•South San Francisco, CA

About The Position

General Description Perform accurate processing of enrollment, disenrollment, and reconciliation transactions for members of CareAdvantage, the Health Plan of San Mateo’s Medicare Advantage/Prescription Drug Plan (MA/PDP). Transactions must be processed in accordance with CMS guidelines for Medicare Advantage plans and Medicare-Medicaid Plans (MMP). Duties & Responsibilities Essential Functions: Process CareAdvantage enrollment transactions in accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines, including timeliness of completion. Contact members to verify accuracy of enrollment form information. Obtain evidence of Medicare and Medi-Cal coverage. Enter and maintain member information in the HPSM database including special flag status, e.g., Medicare Secondary Payer (MSP) and hospice. Reconcile member information between HPSM’s database and Medicare/Medi-Cal information which may include submission of retroactive requests to the CMS Retro Processing Contractor. Submit enrollment information to CMS within required timelines. Investigate and correct enrollment information that has been rejected by CMS due to correctable errors. Send letters to members advising them of enrollment in CareAdvantage. Process voluntary and involuntary disenrollment and related transactions in accordance with CMS guidelines, including timeliness of completion. Contact members and/or their representatives to verify disenrollment. Document the reasons for disenrollment including loss of Medi-Cal eligibility, move out of area. Update the HPSM databases to reflect the enrollment/disenrollment and the effective dates. Assure that the proper information is transmitted to CMS within the required timelines. Send letters to members advising them of disenrollment from CareAdvantage. Professionally represent Plan and Department in internal and external Meetings. Monitor internal and external reports to maintain correct member information and eligibility which also includes adhoc reports. Work closely with the CareAdvantage Navigators in resolving member issues. Work and complete various CMS audits as well as HPSM internal audits to assure quality assurance and timeliness of transactions. Secondary Functions: Perform other duties as assigned.

Requirements

Equivalent to a high school diploma or GED required.
Three (3) years of experience working with persons with disabilities and/or seniors in a medically related field (e.g., physician office, HMO, IPA).
Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint.
Medicare, Medi-Cal and Managed Care.
Work cooperatively with others.
Work as part of a team and support team decisions.
Communicate effectively, both verbally and in writing.
Adapt to changes in requirements/priorities for daily and specialized tasks.
Organize work.
Demonstrate excellent oral and written communication skills with various audiences and individuals of diverse backgrounds particularly when dealing with an elderly and/or medically fragile population.
Perform problem research, use analytical skills, and effectively influence positive outcomes.
Develop and maintain strong professional relationships with a diverse range of people.

Nice To Haves

Experience in managed care enrollment/disenrollment and phone-based customer service highly preferred.
Some positions require fluency in second language, particularly Spanish, Tagalog, Russian or Chinese dialects.

Responsibilities

Process CareAdvantage enrollment transactions in accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines, including timeliness of completion.
Contact members to verify accuracy of enrollment form information.
Obtain evidence of Medicare and Medi-Cal coverage.
Enter and maintain member information in the HPSM database including special flag status, e.g., Medicare Secondary Payer (MSP) and hospice.
Reconcile member information between HPSM’s database and Medicare/Medi-Cal information which may include submission of retroactive requests to the CMS Retro Processing Contractor.
Submit enrollment information to CMS within required timelines.
Investigate and correct enrollment information that has been rejected by CMS due to correctable errors.
Send letters to members advising them of enrollment in CareAdvantage.
Process voluntary and involuntary disenrollment and related transactions in accordance with CMS guidelines, including timeliness of completion.
Contact members and/or their representatives to verify disenrollment.
Document the reasons for disenrollment including loss of Medi-Cal eligibility, move out of area.
Update the HPSM databases to reflect the enrollment/disenrollment and the effective dates.
Assure that the proper information is transmitted to CMS within the required timelines.
Send letters to members advising them of disenrollment from CareAdvantage.
Professionally represent Plan and Department in internal and external Meetings.
Monitor internal and external reports to maintain correct member information and eligibility which also includes adhoc reports.
Work closely with the CareAdvantage Navigators in resolving member issues.
Work and complete various CMS audits as well as HPSM internal audits to assure quality assurance and timeliness of transactions.
Perform other duties as assigned.