Program Manager, Medicare D-SNP Enrollment

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Program Manager, Medicare D-SNP Enrollment is responsible for enrollment activities to provide excellent service to potential and existing Duals Special Needs Plan (D-SNP) members and achieve enrollment goals. 

•    Ensure the accurate, timely processing and data entry of Medicare enrollments into the GCHP D-SNP, re-enrollments and disenrollment, subsequent maintenance of the enrollment data, compliance with regulatory requirements relating to enrollments and disenrollment, filing of applications, prospect and member communication, and other related documents. 

•    Address a variety of enrollment questions or concerns received via claims, call tracking, or email. 

•    Maintain all records in the enrollment database. 

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

•    Responsible for preparation, timely processing of enrollment applications, management, and maintenance in accordance with CMS and DHCS regulations. Ensures compliance with all applicable policies, processes, and procedures.

•    Oversees the enrollment activities and reconciliation.

•    Strong knowledge of the Enrollment process along with State, Federal, and business regulatory requirements and other state specific applications concerning Medicare Enrollment.

•    Ensure quality control of data entered into membership data base and sent to external vendors.

•    Oversees and participates in state, federal, and internal audits, as needed.

•    Responsible for the accurate and timely dissemination of eligibility data to the network, ancillary providers, and internal systems.

•    Ensures staff is complaint with regulatory and company guidelines, including HIPAA compliance.

•    Partners with the Chief, Member Experience to establish departmental goals and objectives that support our mission and goals and ensure that individual performance goals support departmental goals. 

•    Partners with Chief Member Experience and External Affairs Officer to develop performance competencies and metrics that are meaningful and measurable and aligned with our business goals and objectives. Ensures that agreed-upon performance competencies and metrics are meaningful and measurable; implemented timely; communicated and understood by the staff; and metrics are consistently met or exceeded.

•    Oversee and manage the auditing of enrollment and disenrollment information data and certify its completion and accuracy.

•    Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the Medicare Enrollment department.

•    Responsible for ensuring timely reconciliation of eligibility files and adjustments to CMS that meet regulatory and health plan requirements, as required.

•    Coordinate and manage the generation and mailing of all necessary correspondence relating to enrollment, re-enrollment, and disenrollment in accordance with CMS time frames.

•    Partners with vendor management team and the external vendor to ensure service level agreements and regulatory requirements are met.

•    Responsible for communicating and following up on files delayed by CMS and/or State or issues with a file that require Health Plan involvement.

•    Provide excellent customer service to members and providers, answering questions and resolving concerns regarding enrollment and eligibility.

•    Educate members about health plan benefits and services.

•    Review and verify member Medi-Cal and/or Medicare eligibility.

•    Respond to eligibility inquiries from members and providers in a timely and professional manner.

•    Collaborate with internal departments to resolve eligibility-related issues.

•    Monitor Enrollment through Enrollment Manager system.

•    Remediate any system errors related to eligibility and enrollment of members across GCHP systems. 

MINIMUM QUALIFICATIONS

Education & Experience: 

•    Bachelor’s degree in healthcare administration or health care related field

•    A minimum of 3-4 years Enrollment Processing related experience in a Medicare setting

•    Experience with processing of standard enrollment and eligibility files.

•    Experience with external vendor(s) to ensure service level agreements and regulatory requirements are met.

•    Proficient with Microsoft Office applications, including Word, Excel, Outlook and various database applications.

•    Detail oriented with problem-solving abilities. Strong and effective verbal and written communication skills to multi- level audiences.

•    Exemplary interpersonal and customer service skills. Demonstrates professionalism, poise, tact, and diplomacy in interactions with others.

•    Demonstrates good judgment, organization and prioritization skills and time management skills.

•    Proven leadership with staff, projects, and management.

•    Strategic thinking abilities and analytical skills

•    Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.

Equivalent In lieu of degree: Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position.

KNOWLEDGE, SKILLS & ABILITIES    

Preferred Qualifications:    

•    At least 6 years of experience in a Medicare enrollment or eligibility position 

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements

•    Management Skills - Ability to organize and direct oneself and effectively supervise others.

•    Business Acumen - Ability to grasp and understand business concepts and issues.

•    Decision Making - Ability to make critical decisions while following company procedures.

•    Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

•    Interpersonal - Ability to get along well with a variety of personalities and individuals.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

•    Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

•    Consensus Building - Ability to bring about group solidarity to achieve a goal.

•    Relationship Building - Ability to effectively build relationships with customers and co-workers.

•    Presentation Skills - Ability to effectively present information publicly.

•    Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.

•    Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

•    Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

•    Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

•    Judgment - The ability to formulate a sound decision using the available information.

•    Communication, Oral - Ability to communicate effectively with others using the spoken word.  

•    Communication, Written - Ability to communicate in writing clearly and concisely.  

•    Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.