Enrollment Services Representative

Summary/Position Objectives:
Under the general supervision of the Supervisor, Member Services, this position is responsible for ensuring Medicaid and Medicare dual-eligible member data integrity. This includes performing data entry functions, analyzing enrollment discrepancies, and creating and analyzing various reports for all lines of business.

Responsibilities:
Essential Functions:
Performs data auditing and reconciliation functions for Schaller Anderson, Inc. Health plans, primarily Mercy Care Plan and Mercy Care Advantage.
Reports identified system issues, based on EDI criteria, and reports to supervisor for resolution.
Researches and resolves Medicaid, Medicare and Commercial reconciliation reports.
Researches enrollment discrepancies utilizing multiple system applications and makes necessary adjustments to member data files to ensure accuracy under both Medicare and AHCCCS enrollment requirements.
Analyzes all system generated exception reports, corrects errors, and when necessary, coordinates with external agencies and/or internal departments for corrections.
Identifies eligibility issues and takes appropriate action based on complex Medicaid and Medicare eligibility rules and regulations.
Maintains responsible for accurate member data integrity housed in multiple eligibility segments specific to lines of business, including ID cards and correspondence.
Assists in preparation of data compilation for the Supervisor for trending analysis.
Prepares internal Customer and Enrollment Services reports as required.
Prepares system training documents or reference tools for other departments as system errors are found or a need for training is identified.
Researches claims received from the claims department and members, and make appropriate corrections to the member file and send the appropriate documentation to providers regarding billing.
Corrects complex eligibility segment errors identified from coordination of benefits prior to processing claim adjustments.
Acts as an internal liaison for immediate resolution of enrollment issues.
Data enters entire enrollment record for non- automated lines of business.
Accurately processes disenrollment request to ensure accuracy under Medicare requirements.
Works in a manner that is not disruptive to peers, supervisor, and subordinates.
Performs other duties, assignments, and responsibilities as assigned or required.

Secondary Functions:
Must be able to handle multiple projects simultaneously and perform responsibly under processing deadlines.
Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
Must be able to maintain a high level of accuracy in all aspects of responsibilities.
Must maintain regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs (if travel required).
REQUIREMENTS
Knowledge and Skills:
Moderate decision-making responsibility. Requires analyzing data from a variety of different areas, and independent judgment is required to develop appropriate corrective actions based upon Health Plan policies.
Demonstrates ability to interpret Medicaid and Medicare guidelines and determine appropriate action.
Mathematical knowledge including: addition, subtraction, multiplication, division, percentages, ratios, and decimals
Reads, writes and orally communicates at a level to correctly solicit/explain information to members and internal customers.

Education and Work Experience:
Bachelor degree in closely related field is preferred, although an equivalent combination of formal education and experience may substitute for a degree.
Minimum three years experience evaluating and compiling data, with two years in a detail-oriented in a Medicaid Enrollment setting.
Proficiency in word processing, spreadsheets and databases.
Healthcare experience required.
Knowledge of Medicaid and Medicare required.

Work Environment Qualifications:
Position is an office environment. Incumbent may be required to sit for extended periods, entering and manipulating data on a workstation computer and participating in team/executive meetings. Approximately 75% of daily responsibilities will be working both one-on-one and in teams with other personnel and extended one-on-one contact in a quiet environment where hearing and listening is paramount. Occasional requirements are to: stand, walk, use hands to manipulate, handle or feel objects, tools, or controls, reach with hands and arms, stoop, kneel, and lift/move up to 25 pounds. Incumbent may be scheduled to work an alternate schedule to accommodate essential business needs.