Senior Eligibility Specialist

We are searching for a Senior Eligibility Specialist-- someone who works well in a fast-paced setting. In this position, you will validate that member eligibility data is accurate and complete by auditing, reconciling, and updating the data in the claims processing system and the Pharmacy System. Research and resolve member eligibility issues completely, correctly, and timely. Provide a comprehensive and timely response to member eligibility inquiries from internal and external stakeholders.  

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Job Duties & Responsibilities

• Ensure that the Enrollment of all Members is timely and accurate
• Ensure member eligibility data is processed in accordance with Health Plan and department policies and procedures, as well as State guidelines and requirements
• Utilize member eligibility data provided by the State in daily and monthly files (834, Capitation, and Capitation Adjustment)
• Generate reporting for Leadership to reflect the accuracy of all member’s enrollment
• Review discrepancies reporting for correctness, and assign work to the team as needed
• Validate New Member Packets, ID Card Process, Deceased Members Process, and Out of Area Members for accuracy and adhere to HHSC regulatory requirements
• Responsible for resolving complex eligibility inquiries from within the Health Plan and directly with the State
• Communicate with the State, as needed, to assist in researching issues and resolving them
• Request ad hoc reports from IS as needed to support any inbound inquiries and validate the IS reporting for accuracy.
• Works in partnership with IT on testing and implementation of new files and/or file changes, as needed.
• Monitor the Eligibility Group mailbox, and maintain oversight for timeliness and accuracy of responses, ensuring that the department is within the agreed-upon SLAs.
• Review the monthly reconciliation report for discrepancies and assign it to the team.
• Collaborate with IS on any additional reporting that may be needed to support the reconciliation Engage with Finance, the PBM, or the State as needed to address any discrepancies identified during the reconciliation process.

Skills & Requirements

• Required H.S. Diploma or GED. Preferred bachelor's degree
• 4 years Previous experience working at or with an HMO or MCO organization
• A bachelor's degree may substitute for 2 years of required work experience