We enjoy the important work we do every day on behalf of our members.
Under the general supervision of the supervisor/manager, this individual will serve as the key quality control and member maintenance processor for the Enrollment Department. This individual must be able to plan, organize, and prioritize work to ensure completion in a timely manner. He/she demonstrates an ability to follow business processes, to consider options when problems arise, and to identify and escalate issues appropriately. This individual is expected to learn and understand department processes and their interdependencies, contribute to process enhancement opportunities, and support Medicare Preferred and departmental objectives.
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS*
Application Processing and Quality Control
Conduct in depth quality checking
Identify QC trends and areas of opportunity
Maintain QC reports and documentation
Processing of enrollments and plan changes (HMO, MED SUPP, EG, etc...)
Process application disenrollments, cancels, denials, etc. received via email, telephone, action gram, or hand carried.
Review/research/resolve member issues received via service form, e-mail or phone call; document and provide timely response to the member or appropriate department (i.e. Customer Relations, Group Retiree Sales, Appeals & Grievances)
Process the members PCP & IPA changes from Customer Relationship via email or action gram
Update the members address/county changes
Process the termination of deceased members
Process requests from Clinical Services to update member records screen in Diamond
Process action grams from Customer Relations to update members demographic changes
Act as decision maker for routine or non-critical issues; provide input for issue resolution
Cross train new hires and peers as assigned
Document clear and concise Desktop Procedures that can be utilized by various levels of staff
Participate in small to medium projects and workgroups, sharing updates at team meetings
Independently perform extensive testing of new systems/enhancements by creating use cases and reporting findings to measure against expected outcomes
Ensure successful implementation of new processes/products into production as well as ongoing QC
Oversee temps and fulfill assigned mentor role to ensure accurate and timely processing of excessive volume of applications
Assist with audit compilation, as necessary
Contribute to process enhancement opportunities; make proposals and recommendations
Participate in Ad-hoc projects, as necessary
Other duties as assigned
Learn and apply regulatory changes to daily production tasks (i.e. new election periods &codes, transaction code changes, product offerings, re-issuance of guidance)
Responsible for gathering documentation and updating corresponding tracking spreadsheet for the Membership Operations monthly audit program
Complete checklist to ensure all necessary documentation is included
Proactively identify any deficiencies notifying Supervisor, and Compliance Analyst
Actively participate in Corporate Compliance and CMS training (i.e. CBTs, instructor-lead training) and complete within established timeframes
Review, revise, or contribute toward department policy & procedures based on subject matter expertise
Ensure internal procedures and CMS/State requirements are met
Research, validate, and update membership reports for accurate and timely submission to CMS
Participate in various company-wide audits (i.e. HEDIS, Model Audit, Ernst & Young)
Solid communication skills (effective verbal and written skills)
Strong organizational and time management skills
Send/receive email, use Lotus Notes calendar to manage daily activities.
Use applications and business tools (PC, copier, fax machine)
Demonstrate flexibility, commitment, and resiliency in times of business and organizational change
Demonstrate professional demeanor at all times
Support collaboration across Membership Operations and other departments and work cooperatively as a team member.
Provide/accept constructive criticism for improvement, including peer and supervisor feedback for performance management. Coach others to do so.
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
Professional fast paced office environment.
Minimal travel may be required; occasional nights and weekends may be required.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations at all times. HR use only.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!