Purpose and Scope:
The Sr. Enrollment Specialist for Medicare Advantage Prescription Drug (MAPD) plans is responsible for maintaining current and accurate membership records by administering contractually defined eligibility and enrollment period guidelines and processing member transactions. In addition, Sr Enrollment Specialists must be member focused in responding to questions or issues from health plan staff, sales agents and stakeholders regarding insurance benefits and coverage. Responsible for knowledge of Centers for Medicare & Medicaid Services (CMS) regulatory requirements relative to enrollment, disenrollment, eligibility, and CMS transactions impacting plan membership. Responsible for achieving prescribed department performance standards on a consistent basis. Position is onsite and Hybrid work environment available.
Principal Duties and Responsibilities:
- Ensure protocols are being followed to ensure timely resolution and completion of enrollment, disenrollments, cancelations, demographic updates, member/staff communications and all types of requests or transaction related to administering plan membership activities.
- Assist in managing the flow of workload and ensure adherence to processing standards are met or exceeded.
- Follows guidelines in alignment with all health plan requirements as related to guidelines set by CMS
- Follows guidelines in alignment with all health plan requirements as related to guidelines set by CMS for
- Supports special projects focused on Plan growth and promoting membership excellence.
- Works with both internal and external stakeholders to resolve complex enrollment issues, including resolving enrollment responses coming from CMS.
- Interacts with varied levels of management, vendors and physicians effectively to accomplish plan objectives.
- Proactively communicate and collaborate with key stakeholders to analyze information needs and documentation needed.
- Review operational workflows of a high degree of complexity for multiple departments, identifying problems and developing improvements, modifications, and enhancements.
- Document issues resolutions and write specific requirements for system changes and troubleshooting issues to ensure issues as identified, tracked, reported on, and resolved promptly, including creating test scenarios, testing data, and understanding outcomes.
- Assist with managing the day-to-day activities of the process, including establishing priorities and work assignments.
- Conducts quality audits to include Member Reconciliation as required.
- Provide Reports/Statistics upon request.
- Enrollment mailroom activities
- All other duties as assigned.
- Medicare Advantage Prescription Drug (MAPD)
- Customer Focus
- Organizational Skills
- Time Management
- Quality Management
- Problem Solving
- Communication Proficiency
- Presentation Skills
- High School Diploma required. A Bachelor’s Degree is preferred but will accept equivalent experience.
Experience and Required Skills:
- 2-3 years of Medicare enrollment experience in Healthcare Insurance Operations is preferred. Strong background with CMS eligibility protocols and transactions, as it relates to Medicare Advantage Prescription Drug (MAPD) plan enrollment processing.
- Sound working knowledge of CMS guidance in relationship to duties and responsibilities related to MAPD membership management.
- Experience with the MARx application, CMS TRR, TRC and TC systems notification impacting eligibility.
- Ability to organize team members and prioritize across multiple complex projects.
- Proven written and oral communication skills.
- Excellent verbal, analytical, organizational, and written skills.
- Advanced proficiency in Microsoft Office, including Excel.
- Ability to motivate teams and effectively manage personnel.
Gold Kidney Core Values:
Gold Kidney Health Plan is a newly founded Medicare Advantage health plan, will serve Medicare beneficiaries in various counties in Arizona and Florida. Our employees are passionate about providing the best services to our members and healthcare providers. Our corporate office is in Scottsdale, Arizona. To learn more please visit https://goldkidney.com.
I will review and comply with the Code of Business Conduct and all relevant Company and Division policies and procedures, and local, state, and Federal laws and regulations. I acknowledge that I have read and accepted this job description. I understand what is expected of me in this position, and I am able to perform the essential functions as outlined with or without reasonable accommodation. Furthermore, I understand that the duties and responsibilities listed in this job description are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. If I have any questions about duties and responsibilities not specified in this job description that I am asked to perform, I should discuss them with my immediate supervisor or my Human Resources representative.