Operational Support - Enrollment Review Specialist

CommunityCare, Inc.; Tulsa (OK); On-site; USD 42,000 - 64,000; Full time

Job summary

CommunityCare, Inc. is seeking a dedicated Eligibility Quality Reviewer to monitor and review enrollment eligibility changes, ensuring adherence to quality standards and policies.

The role focuses on auditing performance, analyzing monthly data trends, and providing actionable feedback to enhance trainee and staff accuracy. Responsibilities include maintaining quality profiles for enrollment representatives, reviewing eligibility policies, and handling confidential information with

Qualifications

• Strong oral and written communication skills.
• Excellent interpersonal skills.
• Ability to read, analyze and interpret complex documents including health benefit booklets.
• Ability to maintain and preserve information of highly confidential nature.
• Proficient in Microsoft Office applications.
• Successful completion of Health Care Sanctions background check.
• Highly organized and attentive to detail.

Responsibilities

• Reviews the eligibility changes and makes recommendations to improve the effectiveness of the individual representatives.
• Reviews Medicare Advantage TRR changes
• Supports performance guarantees by maintaining quality monitor audits, percentages of accuracy and other data elements as required.
• Identifies and analyzes trends in monthly data to identify improvements and mitigate risk; provides feedback to trainer for continual process improvement.

Skills

Oral and written communication

Interpersonal skills

Reading/comprehending complex health/b

Education

High School diploma or equivalent

College degree preferred

Two years in auditor capacity

Managed healthcare/insurance experience

Understanding of eligibility terms

Eligibility/member experience in managed care

Job description

JOB SUMMARY:

Responsible for monitoring and reviewing eligibility changes for Enrollment department staff to ensure quality standards are met.

KEY RESPONSIBILITIES:

• Reviews the eligibility changes and makes recommendations to improve the effectiveness of the individual representatives.
• Reviews Medicare Advantage TRR changes
• Responsible for supporting performance guarantees by maintaining quality monitor audits, percentages of accuracy and other data elements as required.
• Identifies and analyzes trends in monthly data to identify improvements and mitigate risk. Provides feedback to the trainer for continual process improvement.

• Prepares and maintains quality performance profiles for each enrollment representative.
• Responsible for policies pertaining to eligibility review.
• All other job-related duties as assigned.

QUALIFICATIONS:

• Possess strong oral and written communication skills.
• Excellent interpersonal skills.
• Ability to read, analyze and interpret complex documents including health benefit booklets.
• Ability to maintain and preserve information of highly confidential nature.
• Proficient in Microsoft Office applications.
• Successful completion of Health Care Sanctions background check.
• Highly organized and attentive to detail.

EDUCATION/EXPERIENCE:

• High School diploma or equivalent required; College degree preferred.
• Two years in an auditor capacity. Managed healthcare or insurance industry preferred.
• Understanding of eligibility terms and application.
• Prior working knowledge of eligibility/member related experience in managed care insurance industry. HMO experience preferred.