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 Medicare Enrollment Reconciliation Specialist 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, care 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 Medicare Enrollment Reconciliation Specialist is responsible for reconciling the monthly revenue reporting from CMS – Monthly Membership Report (MMR) and Transaction Reply Report (TRR) – to membership data. This reconciliation process is crucial to enrollment being correct and accounted for as well as ensuring payment from the government is complete and accurate to recognize revenue appropriately. This position identifies variances, performs root-cause analysis and escalates to appropriate parties for decision making. The expectation is timely explanation and remediation of any errors. This position will communicate with cross-functional teams for process improvements on inbound and outbound file exchanges between systems and will provide ad hoc analysis to support operational requests as they relate to membership, commissions, contracts with IPAs, and Internal/External audits. This position will work very closely with Operations but reports directly to Chief Financial Officer.
Responsibilities:
- Analyze and audit enrollment transactions received from CMS.
- Review statistics to measure, audit and analyze identified discrepancies with trend and management reports.
- Resolve finance discrepancies identified via the Revenue Reconciliation Process by submitting discrepancies for review.
- Reconcile all premiums received from CMS.
- Accurately track membership enrollment by IPA, county, age, gender, plan type, RAF score, etc.
- Assists management with reports, reconciliations, and monthly closings.
- Provides ad hoc analysis to support operational requests as they relate to CMS, broker commissions, IPA capitation and risk pool.
- Audits and validates data for conversion and import of Financial & Regulatory files.
- Complete Electronic Data Validation within the CMS timeframes.
- Develops, interprets, and implements financial concepts for financial statement revenues and membership reporting and control.
- Conduct Premium Billing research and perform quality assurance to ensure accuracy of invoices going out.
- Ensure Enrollment and Disenrollment compliance with the Center of Medicare Services (CMS)
- Ensure accurate and timely processing of enrollment file processing (whether automated or manual) and CMS transaction reply to reports for Verda’s Medicare program(s). As part of the CMS file processing, ensure regulatory response transactions are sent to CMS timely along with required member correspondence sent to members.
- Thoroughly document inconsistencies/issues/concerns for follow-up and/or resolution by internal support staff or the software vendor.
- Track the status of assigned tasks and/or related problem issues for completion.
- Aid in the development and maintenance of policies and procedures related to job functions, application configuration, general usage of supported systems and application maintenance.
- Perform other duties as assigned.
Minimum Qualifications
- Bachelor’s degree in finance or related field; equivalent education or experience may be considered in lieu of degree.
- At least 3-5 years of experience in Medicare and/or Medi-Cal eligibility processing required particularly in a health plan setting with demonstrated experience on the following list of stated knowledge, experience and/or skills.
- Experience working with CMS contracted vendors (for example Processing Contractor (RPC), ECRS or MARx) preferred.
Professional Competencies
- Strong project management, analytical, and problem-solving skills.
- Solid communication skills, oral and written.
- Must have advanced skills in Excel in order to ingest and parse data.
- Must have advanced PC skills (MS Office, Word, Access), etc.
- Strong mathematical skills with ability to accept responsibility and work independently.
- Advanced knowledge of and /or database systems, SQL, Oracle, or Access.
- Ability to prioritize multiple projects without compromising desired timelines.
- Strong Healthcare industry knowledge preferred.
- Basic understanding of GAAP
- Knowledge of Managed Care systems and client/server applications preferred.
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
Job Type: Full-time
Benefits:
- 401(k)
- Dental Insurance
- Health insurance
- Life insurance
- Paid time off.
- Vision insurance
Schedule:
- 8-hour shift
- Monday to Friday/Weekends as needed
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.