Senior Representative, Enrollment

JOB DESCRIPTION

Job Summary

The Sr Rep, Enrollment handles all processes related to membership eligibility inquiries and ensures membership accuracy within the system. Represents Enrollment Operations as a subject matter expert (SME) and works collaboratively with external clients and internal partners to resolve membership issues. Utilizes multiple applications and has deep understanding of eligibility related processes.

KNOWLEDGE/SKILLS/ABILITIES

• Completes operational processes to resolve eligibility issues including but not limited to incoming/outgoing eligibility
• Verifies other health insurance to establish primary and secondary payors in the system.
• Reconciles eligibility information with State or Federal Agencies using varied methods.
• Analyzes and assist with complex eligibility issues and provides resolution to internal partners and external clients. and regulators (CMS, Medicaid Agencies, Federal/State Exchanges)
• Responds, documents and tracks and quality assures all proceedings with State and/or Federal Agencies. (including member complaints) within required SLAs (Service Level Agreements)
• Utilize critical thinking skills to proactively communicate eligibility issue trends with Management.
• Manages high volumes of tasks to support regulatory requirements and service level agreements and competing priorities.

• Contributes to technical system enhancements by performing user testing.

  • Participate as a team player by assisting peers and Management to support department goals.

  • Trains new staff on assignments and/or vendors on assignments

• Serves as the Subject Matter Expert (SME) to support production and provides knowledgeable responses to internal and external inquiries regarding eligibility, ID cards, selection of primary care provider, and state enrollment transactions.
• Prioritizes daily, weekly and monthly job tasks to support regulatory requirements and service level agreements.
• Support special projects including regulatory audits
• Member outreach for clarification or verification of enrollment applications
• Resolves the following eligibility exceptions within the required State/Regulatory timeframes: enrollment file errors, ID card generation errors, PCP assignments and 834 enrollment files to vendor/third party administrators.
• Performs enrollment functions to include call tracking, claims workflow, and encounter requests for verification and updates, PCP assignment activity, enrollment record error reports, enrollment/ disenrollment activity
• Displays initiative to complete assigned tasks timely and accurately and balances workload to assist peers and leadership team.
• Strong knowledge of Enrollment processing for Federal, State, and business regulatory requirements with a strong system knowledge of QNXT and State portals, state reports, 834/SSRS, CMS and other Molina Applications. (verify if this knowledge will require to increase experience level in the required education )
• Assist with complex enrollment issues concerning member eligibility.
• Quality review and submission of deliverables to Molina Healthcare Government Contract and to State Medicaid Agencies.

JOB QUALIFICATIONS

Required Education

Associate degree or equivalent combination of education and experiences

Required Experience

• 1-3 years related work experience
• Intermediate Microsoft Excel and Microsoft Word

Preferred Education

Bachelor's Degree or equivalent combination of education and experiences

Preferred Experience

• 3-5 years related work experience
• Basic knowledge ANSI X12 834

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Originally posted on Himalayas