Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:
 
The Eligibility and Enrollment Specialist is responsible for receiving, reviewing, processing, and maintaining new member(s) enrollment information.  The Eligibility and Enrollment Specialist is responsible for monitoring and working to ensure that member eligibility and enrollment requirements/verifications are in compliance with Health Human Services Commission (HHSC) contractual requirements and Utilization Review Accreditation Commission (URAC) standards.  
 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration, as required.

General Duties:
 
· Maintains utmost level of confidentiality at all times.
· Adheres to Health System and Health Plan policies and procedures.
· Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
· Performs all other tasks as assigned by upper management.
· Adheres to department policies, procedures and guidelines.
 
Eligibility and Enrollment Responsibilities:
· Responsible for receiving, reviewing, processing, and maintaining new member(s) enrollment information.
· Responds to member eligibility questions and verifies enrollment status as required.
· Reviews enrollment/eligibility submissions to identify any missing data and to validate information provided; reconcile any discrepancies. 
· Submits files to relevant internal teams; provide any updates/changes/additions to enrollment/eligibility segments as needed to meet deadline requirements. 
· Escalates eligibility and enrollments matters to Maximus and HHSC when required and manages timely resolution of escalations.
· Responsible for answering, verifying and reporting high-volumes of eligibility and enrollment matters.
· Ensures that eligibility and enrollment metrics set by Management are met.
· Maintains compliance with HHSC contractual requirements and URAC standards. 
· Generates reports that track trends and changes over time.
· Understands written communications from Manager concerning the necessary operations of the department and changes that may need to be implemented.
· Maintains productive, timely and effective communication with co-workers and Manager about eligibility and enrollment and departmental issues.
· Assists with member PCP assignments and updates as needed.
· Assists with newborn enrollment until Medicaid approval is verified.

Education and/or Experience:

• Two-year degree or Associate’s degree; or 2-3 years related experience and/or training; or equivalent combination of education and experience.

• Minimum of one year in an eligibility and enrollment environment preferred.

• Minimum of one year Managed Care preferred.

• Strong knowledge of Microsoft Office, including Word, Excel, PowerPoint and Outlook