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Manager Enrollment

Company: Gateway Health Plan
Location: Pittsburgh
Posted on: November 7, 2019

Job Description:

Company : Gateway Health Plan Job Description : I. GENERAL OVERVIEW: Oversees and coordinates day-to-day workflow activities necessary to maintain efficient and effective membership processing across all lines of business, while ensuring adherence to all applicable state and federal regulatory standards. Works with external software vendors to document business requirements for software enhancements/changes as it relates to enrollment. Supports integration of new lines of business, assures processes and procedures are followed and/or identifies areas of risk for new line of business, trains staff and serves as resource for questions. Interacts with third party service providers, business partners, or vendors (such as pharmacy, dental and vision vendors) to assure accurate & timely updates to Gateway's membership records and to subcontractor records based on input from various state and federal entities. II. ESSENTIAL RESPONSIBILITIES: 1. Communicate effectively. * This position displays effective communication skills while performing the functions of this job. * Must communicate effectively with staff, internal department management and external vendors and regulatory entities, thereby requiring good interpersonal skills, excellent problem solving skills, sound judgment, decisiveness, initiative, and a teamwork approach 2. Daily direction of work processes and prioritization with assigned staff monitoring as necessary to ensure accurate & timely updates to membership records, such as * DPW Alerts and weekly enrollment/disenrollment reconciliation * Daily 834 and Legacy reconciliation including error resolution, member updates, status updates * Demographic changes * PCP transfers * Processing all returned mail and mailing member correspondence within federal/state timeliness standards. * Tracking out of area members and requesting member disenrollment. * Reconciling provider capitation errors and PCP terminations * Timely research and response to regulatory agency or legislative requests, audits or complaints related to member data. * Reconciling membership data in third party systems including Pharmacy, Dental & Vision. 3. Interact with Third Party entities such as CMS or DPW, or vendors, such as UCCI or Davis Vision, to ensure accurate and timely membership information in Gateway's system and its subcontractors' systems * Assist Director with oversight of software vendors (DST and PDM) and third party vendors (Argus, UCCI & Dais) and regulatory agencies for enrollment related issues and system modifications. * Participate in testing system upgrades and system setup for new lines of business. * Work with software vendor's customer support staff to troubleshoot membership issues and implement quick resolution. * Interpret HIPAA transaction sets as they relate to membership and capitation files. Identify system software changes necessary to comply with changes to these files and work with software vendor to ensure timely implementation. * Work with subcontractors as necessary to test and implement new enrollment processes and benefit groups. 4. Serve as the subject matter expert for related work processes and systems used to maintain enrollment and membership information for the assigned product * Document processes and requirements and establish operational policies and procedures and ensure accurate implementation * Review existing Gateway policies and procedures on an annual basis, including management of updates and development of new policies, as needed * Participate in interdepartmental and intradepartmental problem solving and quality initiatives. * Prepare and represent the department during internal and external audits, including preparation of records and input on the rebuttal of any findings. * Prepare recommendations for management on process flow, improvements, and system modifications. * Develop training for new department staff and related department staff and corporate overviews as necessary to ensure the appropriate level of knowledge to support the department's objectives and the accuracy of member data. * Prepare required membership reporting for DPW, DOH, CMS and internal monitoring. * Participate in internal and external audit activities including onsite audits and reporting requests. 5. Ensure reconciliation of membership data * Oversee reconciliation process with staff including member discrepancies and suspect generation * Monitor accuracy and timeliness with Quality Assurance Auditor * Oversee the Involuntary Disenrollment process due to Out of Area and State and County Code changes to ensure compliance with CMS monitoring elements. * Prepare various oversight and monitoring reports for the department on a daily, weekly, monthly or quarterly basis as needed for quality, production and backlog monitoring 6. Human Resources and Administration and Budgeting * Manage daily attendance, time off, ESS, performance appraisals, coaching, counseling. * Participate in the interviewing and hiring process. * Provide input regarding operational budget and staffing needs. 7. Other duties as assigned or requested. III. QUALIFICATIONS: Minimum * High school diploma and at least two years related experience * One (1) to three (3) years of previous supervisory or lead position experience in a production environment. * Three (3) or more years of experience in an enrollment department of a managed care organization Note: If servicing DoD programs, the following may be required: o United States citizenship (as required by the Department of Defense) o Successful attainment of a Department of Defense DIACAP security clearance. Preferred * Associates or Bachelors Degree * One (1) year of experience performing Medicare or Medicaid enrollment processing. * Demonstrated skills as it relates to technical expertise and work prioritization, day-to-day staff oversight and problem solving, and technical counseling and coaching. * Experience with Gateway's membership management systems (MHC or PDM) * Experience with reviewing system specifications and file layouts Knowledge, Skills and Abilities * Excellent interpersonal skills with emphasis on ability to effectively communicate both verbally and in writing * Detail oriented individual who is able to work in a fast paced environment with competing and changing priorities. * This job must be able to read, comprehend, and decipher complex notices from regulatory entities, such as CMS and DPW, to ensure that work processes are compliant and be able to document work processes or changes required to ensure compliance. * May be required to assist other product lines to ensure corporate compliance with all deadlines. IV. SCOPE OF RESPONSIBILITY Does this role supervise/manage other employees? Yes If yes, indicate the number of direct reports: 17-21 V. WORK ENVIRONMENT Is Travel Required? Yes * --------------------------------------------------------------------------------------- Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. EEO is The Law Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf) We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

Keywords: Gateway Health Plan, Pittsburgh , Manager Enrollment, Other , Pittsburgh, Pennsylvania

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