Job Description

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.

KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS

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\xe2\x80\xa6)
• Process application disenrollments, cancels, denials, etc. received via email, telephone, action gram, or hand carried.

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

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

Compliance

• 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

Qualifications \xe2\x80\x93 what you need to perform the job

EDUCATION: (Minimum educations & certifications required)

• Associates degree and or some college required; Bachelors 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.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)

• Professional fast paced office environment.
• Minimal travel may be required; occasional nights and weekends may be required.

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations at all times. HR use only.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do\xe2\x80\x94from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

COVID Policy

Please note: As of January 18, 2022, all employees \xe2\x80\x94 including remote employees \xe2\x80\x94 must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R6518

Point32Health