Verda Healthcare, Inc has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan for 2024. We are looking for a Senior Manager, Enrollment & Member Operations to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc and we will support you all the way.
Position Overview
The Senior Manager, Enrollment & Member Operations is responsible for managing enrollment activities to facilitate and enhance the company’s operational and financial goals. Ensure the accurate, timely processing and data entry of Medicare enrollments, re-enrollments and disenrollment, subsequent maintenance of the enrollment data, compliance with regulatory requirements relating to enrollments and disenrollment, filing of applications, and other related documents. Address a variety of enrollment questions or concerns received via claims, call tracking, or email. Maintain all records in the enrollment database.
Job Description
- Responsible for preparation, timely processing of grievances & appeals, enrollment applications, management, and maintenance in accordance with CMS regulations. Ensures compliance with all applicable policies, processes, and procedures.
- Oversees the Grievance & appeal, enrollment activities and reconciliation.
- Strong knowledge of the Grievance & Appeal process, Enrollment process along with State, Federal, and business regulatory requirements and other state specific applications concerning Managed Care
- Ensure quality control of data entered into membership and G&A databases and sent to external vendors.
- Oversees and participates in state, federal, and internal audits, as needed.
- Responsible for the accurate and timely dissemination of eligibility data to the network, ancillary providers, and internal systems.
- Partners with external vendors and is responsible for contracts for Medicare enrollment file transactions to CMS, ID Card printing and mailing and other vendors in support of eligibility operations.
- Oversees external vendors on the development and implementation of tactical initiatives and processes that improve our retention efforts among current members. Keeps Senior Director, Member Experience updated on trends, issues and concerns and success of initiatives.
- Ensures staff is complaint with regulatory and company guidelines, including HIPAA compliance.
- Partners with the Senior Director, Member Experience to establish departmental goals and objectives that support our mission and goals and ensure that individual performance goals support departmental goals. Measures and monitors the status of goal achievement.
- Partners with Senior Director, Member Experience to develop performance competencies and metrics that are meaningful and measurable and aligned with our business goals and objectives. Ensures that agreed- upon performance competencies and metrics are meaningful and measurable; implemented timely; communicated and understood by the staff; and metrics are consistently met or exceeded.
- Oversee and manage the auditing of grievance & appeal, enrollment and disenrollment information data and certify its completion and accuracy.
- Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the Enrollment & Member Experience department.
- Reconcile monthly payments (Monthly Reply Listing Report) and discrepancies between data submitted to CMS and Verda Health Plan records.
- Responsible for ensuring timely reconciliation of eligibility files and adjustments to CMS that meet regulatory and health plan requirements, as required.
- Coordinate and manage the generation and mailing of all necessary correspondence relating to enrollment, re-enrollment, and disenrollment in accordance with CMS time frames.
- Partners with vendor management team and the external vendor to ensure service level agreements and regulatory requirements are met.
- Responsible for communicating and following up on files delayed by CMS and/or State or issues with a file that require Health Plan involvement.
Minimum Qualifications
- Bachelor’s Degree preferred
- 5-7 years Enrollment Processing related experience in Managed Care or Medicare setting
- 3-4 years recent experience Grievance and Appeal processes
- Processing CMS Transaction Files and 834
- Partners with any external vendor(s) to ensure service level agreements and regulatory requirements are met.
- Proficient with Microsoft Office applications, including Word, Excel, Outlook and various database applications.
- Detail oriented with problem-solving abilities. Strong and effective verbal and written communication skills to multi- level audiences.
- Exemplary interpersonal and customer service skills. Demonstrates professionalism, poise, tact, and diplomacy in interactions with others.
- Demonstrates good judgment, organization and prioritization skills and time management skills.
- Proven leadership with staff, projects, and management.
- Strategic thinking abilities and analytical skills
- Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.
Professional Competencies
- Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Written/Oral Communications
- Critical/Analytical Thinker
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
Job Type: Full-time (Full Time Weekend rotation. Schedule to be determined)
Benefits:
- 401(k)
- Dental Insurance
- Health insurance
- Life insurance
- Paid time off.
- Vision insurance
Ability to commute/relocate:
- Reliably commute or planning to relocate before starting work (Required)
PHYSICAL DEMANDS
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
*Other duties may be assigned in support of departmental goals.