Job Location: Smithfield, RI
Position Type: Full Time
Education Level: Bachelor's Degree
Travel Percentage: Occasional
Job Shift: Daytime
Job Category: Management
Description:
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:
- 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 ongoing 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 database, 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.
- Other duties as assigned.
- Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's 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:
- Bachelor's 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 (BRD's).
- 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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