Lead Operations Analyst - EDI and Eligibility

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

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.

POSITION SUMMARY

The Lead Operations Analyst is responsible for managing the eligibility and enrollment processes for GCHP Medi-Cal and Medicare members and ensuring accurate eligibility files. This includes solving cross-functional organizational membership data problems through identification and presentation of business and technical specifications based on business needs, industry best practices and available technology. This role involves working closely with vendors (Core Admin and EDI), regulators, health care providers, and internal teams to facilitate a smooth enrollment experience and ensure compliance with regulatory requirements. This role will also have responsibility for reconciling EDI 834 files and responding to any questions related to such files. This role has responsibility for Enrollment Management, Eligibility Determination, Compliance and Documentation, Customer Service, Reporting and Analysis, and error resolution. All other duties as assigned.

Amount of Travel Required: 30-50% 

Work Schedule: Travel; work protracted and irregular hours and evening meetings or work unusual hours for meeting attendance or participation in specific projects or programs.

ESSENTIAL FUNCTIONS

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 Statements

•    Reporting and Analysis:

•    Generate reports on enrollment statistics and trends as needed.

•    Analyze data to identify areas for process improvement in enrollment and eligibility functions.

•    Consults with multiple business areas and vendors to lead the identification of and documentation of current operational procedures, problems, system input and output requirements, data scope, functional usage, formatting, user screen layout design, workflows and security requirements.

•    Leads operational system requirements definition, testing, training and implementation. Applies use of tools to define requirements and documentation.

•    Writes and maintains functional specifications for new or modified business systems.

•    Consults with programmers to design and develop automated business tools

•    Communicates business requirements and technical specifications to IT programming/development resources.

•    Leads creation of user documentation, instructions, and procedures.

•    Documents and monitors ongoing system issues and leads the coordination and validation of resolution.

•    Develops and/or reviews departmental business system requirements and business systems design documents, and post-implementation plans.

•    Works with internal and external technology partners in implementing new reporting capabilities, systems enhancements and technology.

•    Creates and develops reporting utilizing GCHP and Vendor data warehouses/data marts.

•    Collaboration with call center leaders to implement best practices and reduce the customer service issues while providing exceptional member service.

•    Weekly monitoring to ensure that inquiries are processed in a timely and accurate manner and in accordance with internal and external regulations and guidelines.

•    Create, reviews, edit and update departmental Job Aides, including providing guidance and feedback when applicable.

•    Responds and provides guidance to staff related to escalated eligibility issues.

•    Collaboration with Ventura County Medi-Cal and Medicare agencies office regarding escalated member enrollment data inaccuracies.

•    Research, evaluate and assess reported member enrollment data quality issues and leads the resolution of member enrollment data issues in the GCHP membership/eligibility system in partnership with the County of Ventura, Department of Health Care Services (DHCS) and/or eligibility system administrator.

•    Manages the cost-avoidance initiatives for Long Term Care and Medicare Part A.

•    Oversight of eligibility and member assignment activities in partnership with delegated entities and outsourced vendor. 

•    Acts as business lead and subject matter expert for key strategic initiatives utilizing project management techniques to keep project on track and within scope.

•    Manages budget and maintains appropriate control of resources to ensure ongoing operations are within established budget, productivity, and efficiency standards.

•    Enrollment Management:

     •    Support new members, including verification of eligibility criteria.

     •    Conduct outreach to members to assist with questions and provide guidance on plan benefits.

     •    Medicare related activities to accurately process new member applications, renewals, and cancellations in compliance with regulatory and health plan guidelines.

     •    Maintain accurate records of enrollment activities in the company’s database.

     •    Process, manage, analyze and QA, EDI files and transmissions

•    Eligibility:

     •    Provides analytical support for projects, EDI system problems, including business support for system migrations and consolidations, business area process improvement projects (Operations and Cross Functional), and EDI product installations.

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

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

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

     •    Reconcile 834 EDI eligibility files.

     •    Monitor Enrollment through Enrollment Manager system.

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

•    Compliance and Documentation:

     •    Ensure all processes comply with state and federal regulations.

     •    Prepare and maintain documentation related to enrollment and eligibility for audits and reporting purposes.

     •    Assist in the development and implementation of enrollment policies and procedures.

•    Other Duties:

     •    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.

     •    Any other duties as assigned.

POSITION QUALIFICATIONS

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.

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

•    Customer Oriented - Ability to take care of the customers’ needs while following company procedures.

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

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

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

SKILLS & ABILITIES

Education: Bachelor's Degree (four-year college or technical school) preferred, Field of Study: business administration, health care administration, or related field

Experience:    

•    Minimum of 5 years of experience in health plan Member Services, enrollment, eligibility determination, or a related field. 

•    Familiarity with health insurance products and regulations.

•    Strong analytical and problem-solving skills.

•    Excellent communication and interpersonal skills.

•    Proficient in Microsoft Office Suite and experience with enrollment management software.

•    Ability to work in a fast-paced environment and manage multiple tasks simultaneously.

•    Strong attention to detail and organizational skills.

•    Commitment to maintaining confidentiality and safeguarding member information.

•    Medi-Cal/Medicaid and health experience preferred. 

Computer Skills: Advanced computer skills included in the MS Office products.

Other Requirements:    

Knowledge of:

•    Principles and practices of health care service delivery, managed care, Medicaid enrollment data, eligibility and benefits.

•    Principles and techniques for effective communication and education to serve diverse social and ethnic groups.

•    Appropriate customer service principles and practices, laws, codes, precedents, regulations, executive orders, and other pertinent information related to managed care and Medicaid.