Marketplace Enrollment and Appeals Specialist (PA2) Limited Duration 12 months
About The Position
The primary purpose of the Marketplace Enrollment and Appeals Specialist position is to serve as a Medicaid and Marketplace insurance subject matter expert, applying comprehensive insurance knowledge to analyze complex cases involving eligibility, enrollment, identity verification, technology platform issues, escalations, complaints, and appeals, including review, processing, and decision-making responsibilities. This position evaluates program operations for the state-run technology platform and consumer assistance center (CAC), requiring in-depth analysis of policies, procedures, and system functionality. The Marketplace Enrollment and Appeals Specialist serves as a direct point of contact for contract leads at the CAC and develops operational guidelines and procedures for use by state agencies, insurance carriers, health insurance agents, and community-based organizations, including certified application assisters. This position also supports training and development, compliance, and quality assurance activities for both the technology platform and the CAC.
Requirements
- A Bachelor's Degree in Business or Public Administration, Behavioral or Social Sciences, or a degree related to the agency program that demonstrates the capacity for the knowledge and skills; and two years experience coordinating or administering a program OR Any combination of experience or education equivalent to five years of experience that typically supports the knowledge and skill requirements listed for the classification.
- Knowledge of Medicaid, Medicare, Oregon Division of Financial Regulation programs, and Oregon Health Insurance Marketplace products, policies, and health insurance coverage types.
- Demonstrated experience in healthcare customer service and insurance operations, including resolving complex eligibility, enrollment, identity verification, and case issues.
- Demonstrated experience analyzing complex cases, interpreting program rules, and developing appropriate solutions within established guidelines.
- Strong background in health insurance laws and regulations and their application to casework, appeals, escalations, and compliance-related decisions.
- Ability to exercise sound judgment, impartiality, tact, and diplomacy in high-stress, sensitive, or controversial situations.
- Ability to communicate effectively in writing and verbally with diverse populations, including explaining complex information clearly and accurately.
- Skill in using automated systems, data tracking tools, and standard office software (e.g., spreadsheets, word processing) to manage, analyze, and document information.
- Demonstrated experience supporting or contributing to operational procedures, training, compliance, or quality assurance activities in a program or service environment.
- Experience with Smartsheet and Adobe.
Responsibilities
- Serve as a Medicaid and Marketplace insurance subject matter expert.
- Analyze complex cases involving eligibility, enrollment, identity verification, technology platform issues, escalations, complaints, and appeals.
- Review, process, and make decisions on cases.
- Evaluate program operations for the state-run technology platform and consumer assistance center (CAC).
- Analyze policies, procedures, and system functionality.
- Serve as a direct point of contact for contract leads at the CAC.
- Develop operational guidelines and procedures for use by state agencies, insurance carriers, health insurance agents, and community-based organizations.
- Support training and development, compliance, and quality assurance activities for both the technology platform and the CAC.
Benefits
- Excellent, low-cost medical, vision, and dental coverage for you and your family.
- Optional benefits like life insurance, disability coverage, deferred compensation, and FSA options for health and childcare.
- Generous paid time off: 11 holidays, 3 personal days, monthly sick leave, and vacation accrual starting at 8 hours/month.
- Potential eligibility for the Public Service Loan Forgiveness Program.
- Retirement security through Public Employees Retirement System (PERS)/Oregon Public Service Retirement Plan (OPSRP).
- Training and development opportunities to grow your career with the State of Oregon.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
