The Manager of Enrollment Medicare is responsible for managing enrollment activities for Medicare-Medicaid (MMP) and D-SNP lines of business. This position is accountable for 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. This position works with internal and external stakeholders to address broad, complex enrollment issues. The position also maintains high visibility and accountability to both state and federal entities including the Executive Office of Health and Human Services (EOHHS), Department of Health (DOH), and Centers for Medicare and Medicaid Services (CMS).

Duties and Responsibilities

Responsibilities include, but are not limited to, the following:

Preparation and timely processing of enrollment transactions, management, and maintenance in accordance with CMS regulations.
Ensures compliance with all applicable policies and procedures.
Maintenance of strong knowledge of the Enrollment process along with State, Federal, and business regulatory requirements and other state specific applications concerning Managed Care Enrollment
Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
Ensure quality control of data entered into membership data base, as well as timely and accurate dissemination of eligibility data to internal systems and external vendors and delegated entities.
Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency of member enrollment
Oversees and participates in state, federal, and internal audits, as needed.
Ensure diligent record keeping and audit trails for all relevant inbound and outbound files
Establish and keep current all departmental policies and procedures
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.
Partners with vendor management team and the external vendor to ensure service level agreements and regulatory requirements are met.
Responsible for communicating and following up on files delayed by CMS and/or State or issues with a file that require Health Plan involvement.
Responsible for ensuring timely reconciliation of eligibility files and adjustments to CMS that meet regulatory and health plan requirements.
Partners with vendor management team and the external vendor to ensure service level agreements and regulatory requirements are met.
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

Bachelors degree in Finance, Business or Health related area or equivalent seven (7) + years of experience in Medicare enrollment health care/insurance operations

Knowledge and experience with CMS Transaction Files and 834 Electronic Data Interchange (EDI)
Experience managing delivery through vendor relationships via service level agreements and regulatory requirements
Supervisory experience and proven leadership skills
Proficiency in Microsoft Office applications including but not limited to Word, Excel, Outlook and various database applications
Data driven individual experienced in a transactional production environment
Experience working with technical teams to deliver in support of business objectives
Demonstrated experience translating business needs into formal Business Requirements Documents (BRDs)
Experience in leading User Acceptance Testing (UAT), including documentation and tracking of defects
Experience in monitoring staff production quality and developing staff for quality improvement
Comfort level and demonstrated experience in managing daily prioritization based on a constantly changing technology and business environment.
Solution oriented individual with high comfort level in being flexible and nimble to changing business needs
Strong analytical/problem solving skills
Ability to convey information/ideas clearly and effectively, both verbally and written
Proven ability to develop strong, effective working relationships and work teams
Experienced managing external vendor relationships in the delivery of key business processes
Demonstrated experience with development and executing operational process improvements
Ability to develop business cases and complete Return on Investment (ROI) analysis

Preferred:

MBA or equivalent
Experienced in or willingness to obtain lean methodology and/or six sigma certification

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

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Neighborhood Health Plan of Rhode Island

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Manager of Enrollment Medicare