Operational Support - Enrollment Review Specialist

JOB SUMMARY: Responsible for monitoring and reviewing eligibility changes for Enrollment department staff to ensure quality standards are met.

KEY RESPONSIBILITIES

Reviews the eligibility changes and makes recommendations to improve the effectiveness of the individual representatives. Reviews Medicare Advantage TRR changes Responsible for supporting performance guarantees by maintaining quality monitor audits, percentages of accuracy and other data elements as required. Identifies and analyzes trends in monthly data to identify improvements and mitigate risk. Provides feedback to the trainer for continual process improvement. Prepares and maintains quality performance profiles for each enrollment representative. Responsible for policies pertaining to eligibility review. All other job-related duties as assigned.

QUALIFICATIONS

Possess strong oral and written communication skills. Excellent interpersonal skills. Ability to read, analyze and interpret complex documents including health benefit booklets. Ability to maintain and preserve information of highly confidential nature. Proficient in Microsoft Office applications. Successful completion of Health Care Sanctions background check. Highly organized and attentive to detail. EDUCATION/EXPERIENCE: High School diploma or equivalent required; College degree preferred. Two years in an auditor capacity. Managed healthcare or insurance industry preferred. Understanding of eligibility terms and application. Prior working knowledge of eligibility/member related experience in managed care insurance industry. HMO experience preferred.