Enrollment & Reconciliation Specialist

AlohaCare; United States; On-site; USD 23,000 - 30,000; Full time

Job summary

AlohaCare seeks an Enrollment Reconciliation Specialist to oversee Medicare D SNP enrollment reconciliation and CMSMARx transactions. You will identify discrepancies, investigate root causes, and ensure accurate member eligibility and claims processing.

Required experience in Medicare Advantage/D SNP enrollment, Advanced Excel skills, and the ability to work across teams in a fast-paced environment.

Qualifications

• Requires 3+ years in healthcare enrollment or health plan operations.
• Strong knowledge of CMSMARx enrollment processes and SNP enrollment reconciliation.
• Proficient in Excel and data reconciliation with attention to detail.

Responsibilities

• Identify and investigate discrepancies between CMSMARx systems and downstream systems.
• Research root causes and implement corrective actions for enrollment discrepancies.
• Reconcile Medicare D SNP enrollment with Medicaid eligibility and maintain reconciliation logs.

Skills

CMSMARx enrollment

Data reconciliation

Advanced Excel

Education

High school diploma

Tools

Word

Excel

Access

PowerPoint

Job description

About Us

The Company AlohaCare is a local non profit health plan serving Hawaiis low income residents with free Medicaid and dual Medicare health insurance coverage Our members include children seniors and adults residing on all islands We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care Our approach is to meet the whole person health and social needs of members Through our community partnerships we offer innovative services such as connection to social service agencies Native Hawaiian healing services and in home primary care for qualified members Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all We are Hawaiis third largest health plan and offer a wide network of quality primary care specialists hospitals pharmacies and among many other providers across the state

Company Culture

AlohaCare employees have a passion for helping Hawaiis most underserved communities Our caring culture is fundamental to our company wide team approach to providing high quality services We support our employees with a supportive and positive work environment healthy work life balance continuous communication and a generous benefits package AlohaCares leadership empowers and engages its employees by recognizing outstanding job performance and collaboration We share organization wide updates during quarterly All Staff meetings We encourage participation in volunteer and educational opportunities We put a high value on honesty respect and trust building We encourage open door two way and frequent communication AlohaCares comprehensive benefits package includes low cost medical dental drug and vision insurance paid time off 401k employer contribution referral bonus and pretax transportation and parking program

Opportunity

The Enrollment Reconciliation Specialist provides advanced operational oversight of Medicare D SNP enrollment reconciliation and CMSMARx transactions. This role is responsible for identifying researching and resolving complex enrollment discrepancies that may impact member eligibility claims pharmacy accumulations and regulatory reporting.

Primary Duties and Responsibilities

• Identify and investigate discrepancies between CMSMARx internal enrollment systems and downstream systems
• Research root causes of enrollment discrepancies and develop appropriate corrective actions
• Manage and track member reinstatements retroactive enrollment changes and CMS transaction corrections through resolution
• Reconcile Medicare D SNP enrollment with applicable MedicaidQUEST eligibility and identify issues affecting member eligibility
• Validate enrollment changes and their downstream impact on claims pharmacy member benefits accumulations and other operational systems
• Maintain detailed reconciliation tracker issue logs audit documentation and management reporting
• Identity trends and recurring issues and perform root cause analysis and process improvement
• Provide guidance and subject matter expertise to enrollment staff on complex reconciliation issues and CMS transactions
• Develop and maintain reporting that provides leadership with visibility into enrollment status outstanding discrepancies transaction activity risk and resolution progress
• Escalate significant enrollment issues and potential members or financial impacts to leadership
• All other duties assigned
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures
• Responsible for maintaining AlohaCares confidential information in accordance with AlohaCare policies and state and federal laws rules and regulations regarding confidentiality Employees have access to AlohaCare data based on the data classification assigned to this job title

Requirements

• High school diploma or equivalent
• Minimum of 3 years of healthcare enrollment Medicare Advantage D SNP membership reconciliation or health plan operations experience
• Strong knowledge of CMSMARx enrollment processes
• Experience working with Medicare Advantage and preferably D SNP Medicaid populations
• Advanced Excel and data reconciliation skills
• Demonstrated ability to independently research complex enrollment issues and determine appropriate resolution
• Achieves results builds trust communicate effectively customer and quality focused
• Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization
• Strong effective and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations
• Professional telephonic etiquette skills
• Ability to solve problems analyze think critically and make good judgment
• Strong customer service skills and be able to work in a diverse demanding and evolving environment with strong conflict and problem resolution skills
• Able to work independently with minimal supervision
• Able to effectively work in a fast paced and changing environment manage multiple projects and priorities across multiple teamsprojects and in a matrixed environment
• Possesses excellent time management and organizational skills; is dependable enthusiastic self starting and self motivated Uses time effectively reacts professionally under pressure
• Data entry experience with a high degree of accuracy and attention to detail
• Intermediate skills in Microsoft Programs Word Excel or Access Databases Outlook and PowerPoint
• Experience in the operation of general office equipment to include PC faxcopy machine and phone system
• Available to work a flexible schedule including weekends and holidays when necessary

Preferred Requirements

• Experience with CMS 834 transaction and MARx and RPC processing
• Experience with retroactive enrollment disenrollment and reinstatement processing
• Experience with MedicaidQUEST or integrated MedicareMedicaid programs
• Experience supporting CMS audits and regulatory requirements
• Experience developing reconciliation processes controls and reporting

Mental, Physical and Environmental Demands

Sedentary Work Exerting up to 20 pounds of force occasionally andor a negligible amount of force frequently or constantly to lift carry push pull or otherwise move objects Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. In office working environment May require prolonged sitting up to 4 hours Requires prolonged operation of a computer workstation including the ability to type for extended periods of time on a keyboard during the scheduled workday.

Salary

1700 2200 an hour

Equal Employment Opportunity

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws Our policy prohibits discrimination and harassment because of race color religion sex including gender identity or expression pregnancy age national origin ancestry marital status arrest and court record disability genetic information sexual orientation domestic or sexual violence victim status credit history citizenship status militaryveteran status or other characteristics protected under applicable state and federal laws regulations andor executive orders