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011340 CCA-Portfolio Management

Position Summary

The Specialist, Enrollment Reconciliation documents and conducts procedures related to the reconciliation of Medicaid and Medicare enrollment membership and corresponding premium. The Specialist submits enrollment data and reviews regularly received reports from the Center for Medicare and Medicaid Services (CMS), Massachusetts Medicaid and Commonwealth Care Alliance (CCA) contractors to identify and resolve data discrepancies ensuring compliance and enrollment data quality

Supervision Exercised: No

Essential Duties & Responsibilities

+ Understand, and assure compliance to and adherence with, Medicaid and Medicare enrollment, enrollment regulations related to MAPD, DSNP plans

+ Support the review and update of enrollment workflows

+ Meticulously and accurately execute all reconciliation activities, with a high level of quality and proactively identifying inaccuracies in data of all types.

+ Transfer/Download files from Medicare, Medicaid and other data sources as needed.

+ Review enrollment data reports from Medicare, Medicaid, and CCA contracted vendors to confirm enrollment history.

+ Investigate enrollment data discrepancies, using various internal and external systems to identify the correct information and resolve discrepancies.

+ Gather supporting documentation and submit appeals to Medicaid and or Medicare as appropriate.

+ Review, verify and follow up on appeals submitted to Medicaid and Medicare ensure accurate eligibility updates and premium payment has been received.

+ Perform book of business reconciliation for CCA contracted vendors. Work with identified staff to resolve discrepancies, to identify trends and escalate as needed.

+ Research Prescription Drug Event (PDE) errors to identify and correct information; work with the Pharmacy Benefit Manager (PBM) as needed.

+ Identify and track cases requiring payments to and from other plans in accordance with the Medicare’s Plan to Plan process.

+ Offer recommendations for improvements in CCA and departmental practices to improve workflows and procedures.

+ Research and respond to information requests from Medicare, Medicaid and CCA contracted vendors.

+ Complete productivity and status reports according to the established timeframes.

+ Perform other duties as assigned.

Working Conditions

Standard office conditions.

Required Education

+ Associate degree with 5+ years of experience or High School education with equivalent relevant experience.

Desired Experience

Experience working with Medicaid & Medicare eligibility requirements and enrollment related regulations and processes preferred.

Required** **Knowledge, Skills & Abilities

+ Knowledge of Market Prominence (Enrollment system)

+ Knowledge of Medicare plans (MAPD, DSNP, etc.) and processes

+ Competence to work independently; to prioritize and manage multiple activities and to meet strict deadlines.

+ Demonstrated ability to coordinate work with team members and third parties.

+ Analytical and problem-solving skills.

+ Strong verbal, written and listening communication skills.

+ Proficiency in Microsoft Word and Excel,

Required** **Language(s)

English

Desired Language(s)

bilingual preferred

Other

Standard office equipment

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.