Enrollment Specialist

Toney Healthcare Consulting • Coral Gables, FL

455d • $52,000 - $62,400

About The Position

The Enrollment Specialist is responsible for managing the enrollment process for Medicare and Medicaid beneficiaries, ensuring compliance with CMS guidelines and maintaining accurate member records. This role requires excellent communication skills, attention to detail, and the ability to work independently and collaboratively within a team.

Requirements

• High school diploma or general education degree (GED) required
• A minimum one-year related healthcare industry including Medicare Advantage and Part D experience and patient/beneficiary services
• Understanding of healthcare terminology and definitions
• Strong Verbal/Written communication skills
• MUST HAVE HEALTH PLAN/HEALTH INSURANCE EXPERIENCE
• MUST SPEAK SPANISH FLUENTLY
• MUST HAVE MEDICARE EXPERIENCE

Responsibilities

• Adheres to Processing guidelines to meet Enrollment timeliness requirements as defined by CMS and other regulatory agencies
• Analyze the member application and accompanying documents, ensuring applicant eligibility and match to CMS's records
• Accomplishes daily enrollment, plan changes and disenrollment operations, including application review, entering applications into system and submissions to CMS
• Conduct calls to beneficiaries, to request additional information to be able to process application requests, plan changes, coordination of benefits
• Monitors and works closely with providers to obtain confirmation of condition for members enrolled in SNP plans or with SSBCI benefits
• Identify members
• Be able to reconcile and analyze each section of Daily TRR report, including enrollments and disenrollment's, Multiple Transactions, Special Status Codes, such as ESRD, and State and County Code (SCC), Analyze and update member records
• Contact members via telephone and letter to obtain information necessary to resolve discrepancies
• Generate and process appropriate letters
• Researches eligibility discrepancies and compiles and submits necessary supporting documentation to RPC for correction to CMS
• Be able to process and maintain the Late Enrollment Process, OOA, CSNP and DSNP process
• Review and update PCP reports, error reporting, daily processing files from CMS and other processing related tasks
• Responsible for processing of returned mail to ensure integrity of member records
• Interface with departments to fulfill company and members requests and resolve member issues
• Responsible for informing the Medicare Enrollment Manager of all unresolved issues or questions and act as facilitator to resolve them
• Assist department with all functions on an as needed basis in regards to enrollments, disenrollment's, LEP, OOA, Enrollment and Disenrollment Monthly Matrix, CTM and RPC
• Coordinates with Sales & Marketing department on initial application process
• Performs other duties as assigned
• Ensure proactive customer service techniques with the highest degree of courtesy and telephone etiquette
• Comply with all applicable Policies and Procedures
• May be asked to lift boxes, up to 5 pounds
• Must be able to work overtime, weekends as business necessary
• Review and mail all letters to members in accordance with regulatory guidelines
• Excellent communication skills, verbal and written
• Able to identify priorities, plan work schedule, meet deadlines, able to manage multiple tasks and frequent interruptions
• Reviews monthly CMS reports including: LISHIS, LIS, special TRR, Plan Payment Report, and Demographic Report. Compares reports to eligibility file and resolves any discrepancies
• Work in fulfillment center printing letters, ID Cards, and general mail processing

Benefits

• 401(k)

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: High school or GED
• Number of Employees: 501-1,000 employees