Senior Eligibility Specialist
Full Time
Houston, TX 77024
Posted Today
Job description
At Memorial Hermann, we're about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.
Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.
Job Summary
The Senior Eligibility Specialist is responsible for maintenance of eligibility data, resolving all issues or requests regarding eligibility, facilitating enrollment of potential members, and rendering any needed system updates. Will collaborate in analyzing issues that impact and effect the Eligibility Department's processes and procedures and provide feedback and recommendations. Will serve as subject matter expert, will educate, and mentor Eligibility staff. Job Description
Minimum Qualifications
Education: Associates Degree in Business Management or related field, in lieu of degree two (2) years of claims processing, eligibility/enrollment or member service in a commercial, third party administrator or health insurance environment in addition to qualifications listed below
Licenses/Certifications: (None)
Experience / Knowledge / Skills:
Principal Accountabilities
Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.
Job Summary
The Senior Eligibility Specialist is responsible for maintenance of eligibility data, resolving all issues or requests regarding eligibility, facilitating enrollment of potential members, and rendering any needed system updates. Will collaborate in analyzing issues that impact and effect the Eligibility Department's processes and procedures and provide feedback and recommendations. Will serve as subject matter expert, will educate, and mentor Eligibility staff. Job Description
Minimum Qualifications
Education: Associates Degree in Business Management or related field, in lieu of degree two (2) years of claims processing, eligibility/enrollment or member service in a commercial, third party administrator or health insurance environment in addition to qualifications listed below
Licenses/Certifications: (None)
Experience / Knowledge / Skills:
- Five (5) years of experience in managed care or healthcare customer service, eligibility, finance, or member services; commercial and Medicare experience preferred
- Knowledgeable of and compliant with all relevant laws, rules, regulations and accreditation standards and requirements regarding health plan enrollment operations (ERISA, Department of Labor, HIPAA, Texas Department of Insurance, Centers for Medicare and Medicaid Services, etc.)
- Strong knowledge of provider network arrangements and their relation to eligibility
- Strong understanding of benefit plan design and benefit plan structures such as utilization counters and their relation to eligibility
- Strong working knowledge of CMS enrollment regulations and requirements
- Proficient with Microsoft Access, Excel and Word
- Ability to identify training opportunities within assigned team or mentoring needs of individuals coupled with the necessary communication skills to provide the training
- Ability to interact with various external entities such as health care providers, regulators, employer Human Resources Departments, clients, brokers, and members, etc
- Excellent verbal, written and communications skills
- Ability to perform cross-functionally in a matrix environment as workplace demands require collaboration and assistance between departmental functions
- Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of "we advance health" through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.
Principal Accountabilities
- Audits performance (accuracy and production) of all external organizations delegated to perform eligibility functions; communicates any required data updates to those organizations in a timely fashion.
- Audits all received enrollment forms and enrollment data entered online by brokers, employer human resources departments, and individuals for accuracy and completeness; drafts communiqués with external entities to resolve any questions.
- Processes updates to member eligibility and demographics per information from brokers, employer human resources departments, management, enrollees, other departments, etc., and ensures that requisite documentation is maintained within the document management system.
- Addresses broker, client, and individual questions related to eligibility issues in a timely fashion; monitors departmental e-mail in-boxes, faxes, telephones, and work queues and responds to inquiries and requests accordingly; works to resolve eligibility issues raised by other departments; assists in the enrollment process by documenting and logging enrollment issues.
- Collaborates with management in the preparation of departmental daily and monthly operational and production reports as required.
- Assists management with oversight of eligibility reconciliations and the capture of appropriate documentation supporting any updates to system eligibility records; coordinates the preparation of enrollment files and tracking of enrollment activities.
- Reviews schedules in advance to help organize member outreach; functions as a liaison between department and enrollment vendors; answers telephones and directs calls accordingly or takes accurate messages and refers to the appropriate team.
- Monitors inventory levels of departmental collateral and materials; implements inventory control process system needed to ensure maximum production at all times.
- Collaborates with management in the development and maintenance of departmental policies and procedures and desktop procedures according to current business needs as well as industry and regulatory requirements; assists management with the preparation of training materials and presentation of in-services as requested.
- Assists management in providing member education seminars, meetings, retreats, and special events as necessary; accurately tracks and logs outreach activities as needed; assists individuals and families in navigating and/or enrolling in programs and services through in-person visits and follow-up communication. Provides members with basic health insurance information, including information on policies and procedures, access to care, and enrollment in other programs such as Medicaid, LIS (Low Income Subsidy), or the Memorial Hermann Exchange.
- Communicates, collaborates, and cooperates with internal and external stakeholders in a respectful and responsible manner to enhance relationships and render exceptional service.
- Adheres to all Compliance/Program Integrity requirements.
- Complies with HIPAA Regulations.
- Ensures safe care to patients, staff and visitors, adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
- Performs other duties as assigned.
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