WHO WE ARE:

GlobalHealth is a fast growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

WHO YOU ARE:

The Manager, Eligibility position reports directly to the Director, Enrollment & Fulfillment and is primarily responsible for managing enrollment activities to facilitate and enhance the company’s operational and financial goals.  Ensure the accurate, timely processing and data entry of Medicare enrollments, re-enrollments and disenrollment, subsequent maintenance of the enrollment data, compliance with regulatory requirements relating to enrollments and disenrollment, filing of applications, and other related documents. Address a variety of enrollment questions or concerns received via claims, call tracking, or email. Maintain all records in the enrollment systems.

ESSENTIAL JOB FUNCTIONS:

• Responsible for preparation, timely processing of enrollment applications, management, and maintenance in accordance with CMS regulations. Ensures compliance with all applicable policies, processes, and procedures.
• Oversees the enrollment activities and reconciliation.
• Strong knowledge of the Enrollment process along with State, Federal, and business regulatory requirements and other state specific applications concerning Managed Care Enrollment
• Ensure quality control of data entered into membership database and sent to external vendors.
• Oversees and participates in state, federal, and internal audits, as needed.
• Responsible for the accurate and timely dissemination of eligibility data to the network, ancillary providers, and internal systems.
• Partners with external vendors and is responsible for contracts for Medicare enrollment file transactions to CMS, ID Card printing and mailing and other vendors in support of eligibility operations.
• Oversees external vendors on the development and implementation of tactical initiatives and processes that improve our retention efforts among current members.
• Ensures staff is compliant with regulatory and company guidelines, including HIPAA compliance.
• Partners with the Director, Enrollment and Fulfillment to establish departmental goals and objectives that support our mission and goals and ensure that individual performance goals support departmental goals. Measures and monitors the status of goal achievement.
• Partners with Director, Enrollment and Fulfillment to develop performance competencies and metrics that are meaningful and measurable and aligned with our business goals and objectives.
• Ensures that agreed- upon performance competencies and metrics are meaningful and measurable; implemented timely; communicated and understood by the staff; and metrics are consistently met or exceeded.
• Oversee and manage the auditing of enrollment and disenrollment information data and certify its completion and accuracy.
• Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the Enrollment & Fulfillment department.
• Reconcile monthly payments (Monthly Reply Listing Report) and discrepancies between data submitted to CMS and GlobalHealth records.
• Responsible for ensuring timely reconciliation of eligibility files and adjustments to CMS that meet regulatory and health plan requirements, as required.
• Coordinate and manage the generation and mailing of all necessary correspondence relating to enrollment, re-enrollment, and disenrollment in accordance with CMS time frames.
• Responsible for communicating and following up on files delayed by CMS and/or State or issues with a file that require Health Plan involvement.
• Reviews and analyzes all State agency reports/rosters/premium files and compares eligibility files to validate eligibility and intervene when discrepancies are identified.
• Performs other duties as assigned