Elig & Enrollment Specialist

Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:
 
The Eligibility and Enrollment Specialist is responsible for receiving, reviewing, processing, and maintaining new member(s) enrollment information.  The Eligibility and Enrollment Specialist is responsible for monitoring and working to ensure that member eligibility and enrollment requirements/verifications are in compliance with Health Human Services Commission (HHSC) contractual requirements and Utilization Review Accreditation Commission (URAC) standards.  
 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration, as required.

General Duties:
 
· Maintains utmost level of confidentiality at all times.
· Adheres to Health System and Health Plan policies and procedures.
· Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
· Performs all other tasks as assigned by upper management.
· Adheres to department policies, procedures and guidelines.
 
Eligibility and Enrollment Responsibilities:
 

Specialists report to the Eligibility and Enrollment Manager in the Driscoll Health Plan.  Positions in these classes may perform any or all of the below listed duties.  These should be interpreted as examples of the work and are not necessarily all-inclusive.
 

Eligibility and Enrollment Specialist:  In this position, individuals perform the full range of assigned tasks under supervision, while exercising discretion and independent judgement within established procedures.  Examples of responsibilities include:
· Monthly File Error Correction
· Daily Enrollment Error Correction
· PCP Assignment
· Coverage Creation

· CRM Resolution
· Correcting Pharmacy Issues
· Pharmacy Member Creation
· Newborn Creation

· Newborn Research/ Matching
 
Eligibility and Enrollment Analyst:  In this position, individuals perform the full range of assigned tasks under minimal supervision, while exercising discretion and independent judgement within established procedures.  Examples of responsibilities include:
· Analyzing Newborn data and reconciling it against Claims information
· 2nd Level HHSC E&E Escalation inquiries
· Member data merges
· E&E Monthly, Weekly, Daily Reporting
· Mentorship of Level I and II E&E Specialists
· Defining Processes for E&E workflows
· Data Analysis of E&E Trends
· State Metric Reporting 
· DCH/DHS Coordination for data discrepancies 
· DHS Interdepartmental Process Improvement/Coordination
· Quarterly Upgrade UAT Testing and analysis
 
Essential Responsibilities for the Eligibility and Enrollment Specialist/Analyst
· Responsible for receiving, reviewing, processing, and maintaining new member(s) enrollment information.
· Responds to member eligibility questions and verifies enrollment status as required.
· Reviews enrollment/eligibility submissions to identify any missing data and to validate information provided; reconcile any discrepancies. 
· Submits files to relevant internal teams; provide any updates/changes/additions to enrollment/eligibility segments as needed to meet deadline requirements. 
· Escalates eligibility and enrollments matters to Maximus and HHSC when required and manages timely resolution of escalations.
· Responsible for answering, verifying and reporting high-volumes of eligibility and enrollment matters.
· Ensures that eligibility and enrollment metrics set by Management are met.
· Maintains compliance with HHSC contractual requirements and URAC standards. 
· Generates reports that track trends and changes over time.
· Understands written communications from Manager concerning the necessary operations of the department and changes that may need to be implemented.
· Maintains productive, timely and effective communication with co-workers and Manager about eligibility and enrollment and departmental issues.
· Assists with member PCP assignments and updates as needed.
· Assists with newborn enrollment until Medicaid approval is verified.

EDUCATION AND/OR EXPERIENCE - Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.

• Level Experience Knowledge Skills Eligibility and Enrollment Specialist I

• Two-year degree or Associate’s degree; or 1 year related experience and/or training with High School Diploma; or equivalent combination of education and experience.

• Experience with Microsoft Excel and Word. Experience with health insurance and managed care principles.

• Ability to work independently, or in a team environment, toward meeting common goals.

• Integrity and discretion to maintain confidentiality of member and provider data.

• Ability to apply concepts of eligibility and enrollment following established procedures and workflows for completion of assigned tasks.

• Ability to multi-task and meet deadlines in a fast-paced environment.

• Eligibility and Enrollment Specialist II Two-year degree or Associate’s degree; minimum 5 years of related experience and/ or training with High School Diploma; or equivalent combination of education and experience Proficiency with Microsoft Excel and Word.

• Advanced experience with health insurance and managed care principles.

• Experience with insurance eligibility and enrollment concepts.

• Ability to work independently, or in a team environment, toward meeting common goals.

• Integrity and discretion to maintain confidentiality of member and provider data.

• Advanced analytical skills with ability to collect, organize, analyze and disseminate and communicate information with attention to detail and accuracy.

• Ability to multi-task and meet deadlines in a fast-paced environment.

• Ability to access data in varied formats with different methods of analyzing and processing.