Enrollment Oversight & Quality Specialist

Premera Blue Cross; Lexington (KY); Remote; USD 52,000 - 76,000; Full time

Job summary

Premera Blue Cross is hiring an Enrollment Oversight and Quality Specialist to handle enrollment, eligibility, and billing changes with a focus on accuracy and regulatory compliance. You will support internal teams and external customers via phone, email, or written correspondence within established turnaround times.

The role requires strong customer service skills, the ability to explain administrative guidelines clearly, and participation in occasional late-shift rotations to support business

Qualifications

• Minimum of two years of accounting/finance/bookkeeping experience or enrollment processing experience.
• Associate’s degree in accounting required.
• Strong customer service skills and ability to explain complex information clearly.

Responsibilities

• Review plan provisions and apply rules for Individual or Group enrollment scenarios in compliance with regulations.
• Provide technical support to teams and implementation partners for processing and system issues.
• Research complex systems issues affecting member eligibility and determine appropriate actions.
• Conduct performance audits to ensure transaction accuracy and timeliness and identify process improvements.
• Educate agents and members on billing processes and administrative rules.

Skills

Customer service

Communication

Attention to detail

Education

Associate’s degree in accounting

Tools

Accounting software

Job description

Workforce Classification:

Telecommuter

Join Our Team: Do Meaningful Work and Improve People’s Lives

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for.

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Enrollment Oversight and Quality Specialist

will perform moderate to complex enrollment, eligibility, billing changes and reconciliation, and account research using a variety of methods, systems and platforms. This role is expected to have exceptional customer service skills and interact with internal and external customers in a timely and professional manner via phone, email or written correspondence within established department turnaround times. Must be able to thoroughly explain administrative and regulatory guidelines, their impact and offer alternatives to our members/agents. This position will provide support and coordination to assist in the management and improvement of assigned audit processes. This role will include the development, maintenance and tracking of related audits, procedures, and efficiency work in team and as it relates to our strategic implementation partners.Candidates must be available to support business operations during the department's 7:00 AM to 5:00 PM PT coverage window. This role also requires participation in a late-shift rotation, typically one day per week, with occasional additional coverage based on business needs. Late-shift hours are 8:30 AM to 5:00 PM PT.

What you will do:

• Responsible for reviewing plan provisions and applying specific rules inherent to Individual or Group enrollment scenarios. Apply contractual, state and federal guidelines as appropriate, ensuring work follows federal and state regulations.
• Provides technical support to assigned teams/strategic implementation partners by researching and/or troubleshooting issues related to processing, system, and software applications.
• Serves as a resource for customers by researching complex systems issues impacting member eligibility and determining appropriate course of action. Escalate issues or concerns to ensure desired results.
• Conduct performance audits to ensure transaction compliance, accuracy and timeliness. Identifies, recommends and implements process improvements.
• Represents department on cross-functional teams and meets with external customers as required.
• Regularly reviews procedures and training material for in-team and strategic implementation partner training, through partnership with the training and quality coaching teams, to outline and implement improvements for increased efficiency.
• Provide back-up and peak-load assistance across Enrollment & Billing as needed; complete special projects and perform other duties as assigned.
• Tracks, monitors, updates, and follows-up with strategic implementation partner on audit findings, action plans, and information requests to ensure each item on the action plan is completed in a timely and accurate manner.
• Process plan changes, dependent add-ons, direct transfers, transfer accumulators and more challenging types of enrollments. Update eligibility, enrollment and/or billing of accounts.
• Contact customers or Producer agents for enrollment clarification and/or to provide administrative/regulatory guidelines. This may include creating written correspondence regarding complex billing and enrollment issues.
• Must meet or exceed department production and quality standards and remain current on company/departmental policies and procedures.
• Educate agents and members on general membership and billing processes and administrative rules; may include Web portal usage and contract or regulation interpretation.
• Perform other duties as assigned.

What you will bring:

• High School diploma or GED.
• (Required) Minimum of two (2) years of accounting/finance/bookkeeping experience or two (2) years enrollment processing experience.
• (Required) Associate’s degree in accounting.
• (Preferred) Previous customer service experience.
• (Preferred