Manager, Membership & Eligibility

VNS Health; New York (NY); On-site; USD 93,000 - 117,000; Full time

Job summary

An established industry player is seeking a dedicated Operations Manager to lead the Membership and Eligibility Unit. This pivotal role involves overseeing enrollment processes, ensuring compliance with CMS guidelines, and managing a team to optimize membership functions. The ideal candidate will have extensive experience in healthcare supervision, a strong grasp of Medicare and Medicaid policies, and exceptional communication skills. Join a nonprofit organization committed to delivering compassionate care and innovative health solutions, making a meaningful impact in the lives of thousands across New York.

Qualifications

• 5+ years of supervisory experience in healthcare settings.
• Strong knowledge of Medicare and Medicaid policies.

Responsibilities

• Oversees enrollment processes ensuring data accuracy.
• Manages reconciliation for membership activities.
• Prepares financial reports ensuring compliance.

Skills

Medicare Knowledge

Medicaid Knowledge

Reconciliation Systems

Excel

Access

Word

Communication Skills

Education

Bachelor's Degree in Business Administration

Master's Degree (preferred)

Job description

Overview

Manages the day-to-day operations of the VNS Health Plans Membership and Eligibility Unit (MEU), focusing on enrollment and disenrollment activities, member premium billing/collections, and prescription drug event reconciliation for all VNS Health Plans Medicare product lines and the Fully Integrated Dual Advantage (FIDA) plan. Supervises Third Party Administrator (TPA) entities and vendors to ensure smooth data transfer and compliance with CMS and SDOH guidelines. Develops internal control procedures to optimize membership and eligibility functions, working under general direction.

Key Responsibilities:

1. Oversees the enrollment process from application receipt to final determination, ensuring data accuracy and system integrity.
2. Manages reconciliation processes for TPA membership activities, audits membership data, and ensures adherence to CMS guidelines.
3. Coordinates audits, reviews documentation, and collaborates with auditors to ensure compliance and improve outcomes.
4. Analyzes CMS and State reports to maintain accurate membership data and eligibility status.
5. Monitors communication flows among staff, vendors, and providers to ensure proper handling of eligibility requests.
6. Verifies monthly premium payments, reconciles CMS payment census, and addresses discrepancies.
7. Ensures members meet eligibility criteria, monitors Medicaid validations, and manages cases of ineligibility.
8. Oversees processes related to LEP, COB, Employer Subsidy, RFI, and Retroactive Processing, ensuring CMS compliance.
9. Assists in developing and distributing membership materials, ensuring regulatory compliance.
10. Monitors Medicare Part D billing, reviews reports, and manages error resolution with PBMs.
11. Reviews TrOOP reports, adjusts eligibility as needed, and liaises with CMS and vendors.
12. Prepares financial reports on AR and AP, ensuring CMS payment compliance.
13. Reviews sales agent commissions and vendor issues, suggesting improvements.
14. Acts as liaison to TPA vendors, monitors policies, and implements operational improvements.
15. Maintains up-to-date knowledge of Medicare and Medicaid policies, providing staff training and guidance.
16. Performs managerial duties, including staff productivity monitoring and development.
17. Participates in special projects and performs other duties as assigned.

    Qualifications

    Education:
    Bachelor's Degree in Business Administration, Health Administration, or related field required. Master's preferred.

    Work Experience:
    At least five years of supervising staff, preferably in healthcare. Strong knowledge of Medicare, Medicaid, and reconciliation systems. Proficiency in Excel, Access, Word. Excellent communication skills.

    Compensation

    $93,400.00 - $116,800.00 annually.

    About Us

    VNS Health is a leading nonprofit home and community-based health care organization, dedicated to providing compassionate care and innovative health solutions for over 130 years. We serve more than 43,000 individuals through our extensive services and health plans across New York and beyond.