Watertown, MA 02472
Under the general supervision of the supervisor/manager, this individual will serve as the key quality control and member maintenance processor for the Enrollment Department. This individual must be able to plan, organize, and prioritize work to ensure completion in a timely manner. He/she demonstrates an ability to follow business processes, to consider options when problems arise, and to identify and escalate issues appropriately. This individual is expected to learn and understand department processes and their interdependencies, contribute to process enhancement opportunities, and support Medicare Preferred and departmental objectives.
Application Processing and Quality Control
- Conduct in depth quality checking
- Identify QC trends and areas of opportunity
- Maintain QC reports and documentation
- Processing of enrollments and plan changes (HMO, MED SUPP, EG, etc )
- Process application disenrollments, cancels, denials, etc. Received via email, telephone, action gram, or hand carried.
60% Member maintenance:
- Review/research/resolve member issues received via service form, e-mail or phone call; document and provide timely response to the member or appropriate department (i.E. Customer Relations, Group Retiree Sales, Appeals & Grievances)
- Process the members PCP & IPA changes from Customer Relationship via email or action gram
- Update the members address/county changes
- Process the termination of deceased members
- Process requests from Clinical Services to update member records screen in Diamond
- Process action grams from Customer Relations to update members demographic changes
- Act as decision maker for routine or non-critical issues; provide input for issue resolution
20% Projects/Other Assignments
- Cross train new hires and peers as assigned
- Document clear and concise Desktop Procedures that can be utilized by various levels of staff
- Participate in small to medium projects and workgroups, sharing updates at team meetings
- Independently perform extensive testing of new systems/enhancements by creating use cases and reporting findings to measure against expected outcomes
- Ensure successful implementation of new processes/products into production as well as ongoing QC
- Oversee temps and fulfill assigned mentor role to ensure accurate and timely processing of excessive volume of applications
- Assist with audit compilation, as necessary
- Contribute to process enhancement opportunities; make proposals and recommendations
- Participate in Ad-hoc projects, as necessary
- Other duties as assigned
- Learn and apply regulatory changes to daily production tasks (i.E. New election periods &codes, transaction code changes, product offerings, re-issuance of guidance)
- Responsible for gathering documentation and updating corresponding tracking spreadsheet for the Membership Operations monthly audit program
- Complete checklist to ensure all necessary documentation is included
- Proactively identify any deficiencies notifying Supervisor, and Compliance Analyst
- Actively participate in Corporate Compliance and CMS training (i.E. CBTs, instructor-lead training) and complete within established timeframes
- Review, revise, or contribute toward department policy & procedures based on subject matter expertise
- Ensure internal procedures and CMS/State requirements are met
- Research, validate, and update membership reports for accurate and timely submission to CMS
- Participate in various company-wide audits (i.E. HEDIS, Model Audit, Ernst & Young)
- Annual of review of CMS Chapters
EDUCATION: (Minimum educations & certifications required)
- Associates degree and or some college required;
- Bachelor s degree preferred.
EXPERIENCE: (Years of experience)
- 1-3 years business experience.
SKILL REQUIREMENTS: (Include interpersonal skills)
- Research/Analytical skills
- MS Office skills, with focus on Excel
- Solid communication skills (effective verbal and written skills)
- Strong organizational and time management skills
- Send/receive email, use Lotus Notes calendar to manage daily activities
- Use applications and business tools (PC, copier, fax machine)
- Demonstrate flexibility, commitment, and resiliency in times of business and organizational change
- Demonstrate professional demeanor at all times
- Support collaboration across Membership Operations and other departments and work cooperatively as a team member.
- Provide/accept constructive criticism for improvement, including peer and supervisor feedback for performance management. Coach others to do so.
Meet Your Recruiter
Director, Client Services
Ashley Dineen has been with The Panther Group since 2009 and has worked within many areas of the company including payroll, compliance, on-boarding, recruitment, and client management.
Ashley is a mother of two and enjoys spending time with family in her spare time.