Medicare Enrollment Manager

Description

Salary Range: $101,007 - $151,510

Job Summary

TThe Medicare Enrollment Manager at CenCal Health, holds a leadership role within the Customer Experience Division, reporting to the Director of Member Services. This position is responsible for oversight of our vendor and the Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS) and overseeing and managing all enrollment-related transactions. The Medicare Enrollment Manager ensures the accurate, timely processing and data entry of Medicare enrollments, re-enrollments and dis-enrollments, subsequent maintenance of enrollment and eligibility data, compliance with regulatory requirements, filing of applications and other related materials; to facilitate and enhance CenCal Health’s operational and financial goals for a high-quality and fully compliant D-SNP product line.

Duties and Responsibilities

• Manage the enrollment process for D-SNP members, including coordinating enrollment activities with CMS and DHCS, ensuring compliance with federal regulations and contractual obligations.
• Responsible for the accurate and timely dissemination of eligibility data to the network, ancillary providers, and internal systems. Communicating and following up on files delayed by CMS and/or State or issues with a file that require Health Plan involvement.
• Oversees external vendors on the transactional processes and development and implementation of tactical initiatives that improve our retention efforts among current members. Keeps Director of Member Services and the Medicare Director updated on trends, issues, concerns and success of external vendor oversight and monitoring.
• Identifies and implements audit processes to ensure quality assurance and compliance with regulatory standards on all enrollment and eligibility related work.
• Address a variety of enrollment and eligibility questions or concerns received via claims, call tracking, or email. Maintain all records of interactions in the enrollment database.
• Coordinate and manage the generation and mailing of all necessary correspondence relating to enrollment, re-enrollment, and disenrollment in accordance with CMS timeframes.
• Partners with the Director of Member Services and the Medicare Director to establish departmental/organizational goals and objectives that support our mission and goals.
• Partners with Quality and Population Health, Health Equity and Program Development, Cultural & Linguistic Access Program, and others to ensure health equity in the enrollment and eligibility workflow and transactions.
• Measures and monitors the status of goal achievement.
• Partners with the Director of Member Services and the Medicare Director to develop performance competencies and metrics that are meaningful and measurable and aligned with our business goals and objectives; and ensure that metrics are consistently met or exceeded.
• Develop and implement internal strategic initiatives to optimize enrollment and eligibility processes, enhance efficiency, and minimize errors or delays.
• Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the Eligibility and Enrollment staff within Member Services.
• Collaborate with cross-functional teams including IT, Compliance, Finance, Marketing and Sales and other operational departments to identify and streamline enrollment workflows and resolve complex issues.
• Monitor enrollment and eligibility data daily, weekly and monthly for accuracy and completeness, identify and address any discrepancies or issues, and implement quality improvement initiatives as needed.
• Assists with third-party recovery and Medicare reconsideration request reconciliation, along with the investigation, correction, and tracking of enrollment transactions as necessary.
• Perform monthly reconciliation monitoring between CenCal Health enrollment and the CMS Payment Report to identify discrepancies.
• Serve as the primary point of contact for CMS regarding enrollment-related matters, maintaining strong relationships and ensuring open communication.
• Stay informed about changes in CMS and DHCS regulations, policies, and procedures related to enrollment and eligibility, and ensure timely implementation of required internal policy and procedural updates.
• Perform all other duties as assigned, contributing to the overall success and operational efficiency of the department, and CenCal Health.

Qualifications

Knowledge/Skills/Abilities

• Strong knowledge of the Enrollment and Eligibility processes along with State, Federal, and business regulatory requirements and other state specific applications concerning Managed Care Enrollment. Experiencing processing CMS Transaction Files and Medi-Cal 834 eligibility.
• Proven track record of leadership in healthcare operations, specifically in Medicare and Medicaid/Medi-Cal enrollment.
• Extensive knowledge of CMS enrollment guidelines, regulations, and compliance requirements.
• Strong analytical skills with the ability to interpret data and make data-driven decisions.
• Detail oriented with problem-solving abilities.
• Strong and effective verbal and written communication skills to multi- level audiences.
• Demonstrates good judgment, organization and prioritization skills and time management skills.
• Excellent communication and interpersonal skills, with the ability to build effective relationships internally and externally. Demonstrates professionalism, poise, tact, and diplomacy in interactions with others.
• Experience managing teams and driving organizational change.
• Ability to thrive in a fast-paced environment and manage multiple priorities effectively.
• Commitment to quality, accuracy, and continuous improvement to meet or exceed key performance indicators.
• Proficient with Microsoft Office applications, including Word, Excel, Outlook and various database applications.

Education and Experience

• Bachelor's degree in Healthcare Administration, Business Administration, Public Health, or a related field, or an equivalent combination of education and experience.
• 5-7 years’ experience leading enrollment processes in the insurance industry, with a particular focus on enrollment in Medicare Advantage, is strongly preferred.
• Certification in Healthcare Compliance (CHC) or similar credentials are a plus.

Salary : $101,007 - $151,510