Job Description

Job Description

Job Description

Summary
This position is responsible for managing the functional areas and staff of
eligibility, enrollment and billing operations for all lines of business. This includes
monitoring all aspects of these functional areas to ensure quality, production, and
regulatory requirements are met.
Essential Duties and Responsibilities include the following:
• Manages the functional areas and staff that perform eligibility and
enrollment operations.
• Develops and maintains proper controls to ensure inbound and outbound
data and documents are processed within expected performance standards.
• Maintains communication with all internal and external enrollment
production teams to ensure deadlines are met and quality checks are
performed.
• Maintains quality assurance program and manages a quality assurance
enrollment specialist to monitor in- and outbound billing and eligibility file
accuracy, including but not limited to 834, Coordination of Benefits,
invoice, and pharmacy eligibility files.
• Establishes audit tools and procedures to provide necessary quality
assurance for functional areas; monitors expenses in full compliance with
established budgets and policies.
• Supports and coordinates the activities of external eligibility and
enrollment vendors by establishing desktop procedures, queues, routing
and workflow rules, and ensuring the vendors receive accurate and current
information related to company products, networks, client groups, and
policies.
• Monitors operations and performance of external vendors to ensure
accuracy and production standards as well as regulatory requirements are
met; reviews all pertinent vendors as part of creating consistent
Scorecards and initiating Quarterly Reviews.
• Manages daily enrollment and disenrollment operations related to
beneficiaries in Medicare Advantage products including receipt, tracking,
reviews and processing of applications, all required submissions to CMS,
and obtaining missing information and initiating any necessary corrections
to CMS or Retroactive Processing Contractor (RPC).
• Manages daily enrollment/eligibility and disenrollment operations related
to Commercial products including receipt, tracking, reviews and processing
of applications within required timelines including obtaining missing
information and initiating any corrections with employer groups as
necessary.
• Responsible for the research and resolution of any identified discrepancies
or issues with Medicare enrollment or commercial eligibility;
• Oversees associated regulatory reports including Demographic Reports,
Monthly Membership Reports, Plan Payment Reports, Transaction Reply
Reports, Working Aged surveys, monthly attestations, regional office
letters, etc.
• Designs, tests, and deploys Monthly Reporting Dashboard.
• Manages the preparation of departmental daily and monthly operational
and production reports as required; provides the leadership team with
performance reports concerning the number of applications processed
daily, weekly, monthly, quarterly, and yearly.
• Assists sales and marketing initiatives of the organization in providing
member education seminars, meetings, retreats, and special events as
necessary..
• Oversees the assistance to individuals and families in navigating and/or
enrolling in programs and services through in-person visits and follow-up
communication and the provision to members of basic health insurance
information such as access to care and enrollment in other programs such

• as Medicaid, LIS (Low Income Subsidy), or other products as appropriate.

• Develops and trains departmental staff through coordination of training
materials and presenting in- services to ensure that employees have the job
competencies necessary to meet performance and quality standards in
their current roles and to enhance their future growth and potential;
motivates subordinates, establishes teamwork, and builds employee
morale.
• Develops and maintains departmental policies and procedures and desktop
procedures according to current business needs as well as industry and
regulatory requirements; ensures appropriate and effective departmental
goals and objectives are developed, implemented, and monitored in
accordance with company standards and operational and regulatory
requirements.
• Communicates, collaborates, and cooperates with internal and external
stakeholders in a respectful and responsible manner to enhance
relationships and render exceptional service.
• Adheres to all Compliance/Program Integrity requirements.
• Complies with HIPAA Regulations.
• Promotes individual professional growth and development by meeting
requirements for mandatory/continuing education and skills competency;
supports department-based goals which contribute to the success of the
organization; serves as preceptor, mentor and resource to less experienced
staff.

Qualifications:
• Education: Bachelor’s Degree is required; Bachelor’s Degree in health
care administration, business or related field is preferred
• Ability to work from home with appropriate internet access and a quiet and
private workspace.
• Five (5) years of experience in a management role in managed care or
healthcare eligibility, enrollment, or member services; commercial and
Medicare experience strongly preferred.
• Knowledgeable of and compliant with all relevant laws, rules, regulations
and accreditation standards and requirements regarding health plan
enrollment and billing operations (ERISA, Department of Labor, HIPAA,
Texas Department of Insurance, Centers for Medicare and Medicaid
Services (CMS), URAC, etc.)
• Firm grasp of CMS regulations and requirements; experience with all
aspects of Medicare enrollment
• Conversant with benefit plan designs and plan structures such as
utilization counters and their relation to eligibility; good understanding of
provider network arrangements and their relation to eligibility
• Ability to multitask in a fast-paced environment.
• Proficient computer skills, specifically with Microsoft Office and Windows.
• Proficient analytical and research abilities.
• A desire to serve others while being empathetic with the drive to go above
and beyond to help resolve questions at the first point of contact.
• Must have a strong work ethic and a sense of responsibility to other team
members and external stakeholders to meet all needs represented by a
robust sense of accountability
• Adaptable and a quick learner, willing to change to meet shifting customer
and business needs.
• Excellent verbal and written communication skills
• Extremely organized and detail oriented.
• The ability to develop effective working relationships, and work
collaboratively with all levels of staff, vendors, and partners.

About Apex Health Solutions
Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers
and providers, generating unparalleled value. Combined with Apex’s experienced
and successful industry leadership, our focal point remains on improvement in
patient quality, satisfaction and overall cost of care.
The above job description is not intended to be an all-inclusive list of duties and
standards of the position. Incumbents will follow any other instructions, and
perform any other related duties, as assigned by their supervisor

Job Tags

For contractors, Shift work,

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