Enrollment Specialist Lead

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The Enrollment Specialist Lead serves as a subject matter expert in functional areas related to enrollment across lines of business including the proficient, timely, and accurate entry and maintenance of member eligibility and enrollment data. This position is also responsible for assisting with supervisory responsibilities and helping to ensure compliance with relevant internal, state, and federal guidelines and department procedures.

Estimated Hiring Range:

$25.42 - $31.07

Bonus Target:

Bonus - SIP Target, 5% Annual

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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Essential Responsibilities

Technical

• Perform eligibility and enrollment functions including reconciliation of member enrollment and demographic information.

• Utilize private health data using multiple systems.

• Resolve discrepancies between enrollment and eligibility systems.

• Process incoming Medicare and/or Medicaid enrollments according to applicable state, federal, and internal CareOregon guidelines.

• Investigate other health insurance coverage status to assist with coordination of benefits.

• Ensure compliance with timely processing of eligibility, enrollment records, and/or member notification.

• Resolve very complex enrollment and compliance issues.

• Assist in the research and resolution of member grievances and complaints, including CMS Complaint Tracking Module responses.

• Lead the development of documentation and process guides for relevant OHA and/or CMS enrollment functions.

• Assist with User Acceptance Testing for projects and system implementations as needed.

• Support the most complex Medicare member Disenrollment and Cancellation from CMS, including Retro-Disenrollments, submission to the CMS Retro Processing Center, and tracking status updates.

• Act as an information resource for the team regarding eligibility and enrollment functions.

• Serve as a project or process owner within the department.

• Assist the supervisor in monitoring enrollment reports and deliverables to ensure timeliness and compliance, including annual and semiannual deliverables such as HEDIS and Part D CMS submissions.

• Assist supervisor to collaborate with other teams and programs on process improvement and interdepartmental workflows.

• Gather and organize documentation for periodic state and federal audits.

• Assist with gathering business requirements for changes to the enrollment process.

• Assist supervisor with monitoring outbound file deliveries to business partners.

• Support troubleshooting of inbound and outbound enrollment file deliveries.

• Monitor OHA and/or CMS communications to support implementation of required changes

• Engage with OHA and/or CMS in plan collaboration meetings.

• Perform the functions of an Enrollment Specialist when needed.

Customer Service

• Assist internal and external business partners, sales agents and members regarding enrollment related inquiries such as benefit levels, eligibility status, sales support, grievances, and audits and appeals.

• Work collaboratively with internal and external business partners to ensure effective customer service and resolve enrollment-related inquiries.

• Use online call tracking system to document all activities from any mode of communication from members, providers and other customers.

• Maintain confidentiality for all customers.

• Treat all customers with honesty, courtesy, dignity and respect.

• Handle escalated phone calls to provide problem resolution when needed.

• Provide customer service guidance as needed to Enrollment Specialist staff.

Outbound Calls

• Conduct outbound calls to Medicaid and/or Medicare members, to assist with eligibility and enrollment.

• Conduct outbound calls to external business partners for eligibility verification and enrollment inquiries.

Employee Supervision

• Provide leadership for a team in support of team direction and goals.

• Provide input into staffing needs; assist in recruiting and hiring staff, using an equity, diversity, and inclusion lens.

• Participate in organizing, scheduling, monitoring and improving work; help ensure employees have information to meet job expectations and have coverage during absences.

• Contribute to the development, communication, and oversight of team and individual goals.

• Train, lead, and coach employees; may facilitate team meetings.

• Incorporate guidance from CareOregon equity tools into people leadership.

• Help monitor employee adherence to department and organizational standards, policies, and procedures.

• Assist in evaluating employee performance, providing feedback to support success, recognizing strong performance, and addressing performance gaps and accountability (corrective action).

• Perform lead tasks in collaboration with Human Resources as needed.

Experience and/or Education

Required

• Minimum 5 years’ experience in healthcare or insurance in customer service, enrollment, billing or related area

-OR-

• Minimum 3 years’ experience in Medicare or Medicaid enrollment

• Experience working with CMS and/or OHA 

Preferred

• Experience in a training, coaching or lead role

• Experience with people and/or project leadership

Knowledge, Skills and Abilities Required

Knowledge

• Advanced understanding of the concepts of managed care

• Expert knowledge of Medicare and Medicaid eligibility and enrollment requirements

• In-depth knowledge of enrollment processes and functions across lines of business and ability to act as an enrollment Subject Matter Expert in one or more lines of business

Skills and Abilities

• Advanced understanding of and ability to apply Oregon Administrative Rules (OARs) federal laws and other regulatory requirements that relate to the medical, dental, mental health and health insurance industry and/or Medicaid/Medicare industry

• Very strong skills in Microsoft Windows, Word and Outlook

• Advanced skill in Excel

• Basic or intermediate understanding of EDI 834 file exchange

• Very strong skill in the use enrollment systems 

• Ability to continually generate new ideas to improve quality and productivity

• Expert ability to communicate effectively with leadership and be a back-up representative for the Supervisor in inter-departmental meetings

• Expert ability to work in a fast-paced environment and manage multiple tasks

• Advanced and effective research, analytical and problem-solving skills

• Expert ability to adhere to a set schedule and sustain excellent attendance

• Expert ability to learn and apply basic knowledge, including completion requirements for CMS systems certifications and re-certifications (HPMS)

• Ability to assist with system implementation and configuration

• Ability to model professional behavior, support coaching, and assist with development plans for enrollment staff

• Advanced customer service skills, including the ability to interact professionally, patiently, and courteously over the phone

• Strong active-listening skills

• Excellent written and oral communication skills

• Ability to articulate very complex issues in an easy-to-understand manner

• Ability to share information and insight and give clear and concise information, directions and feedback

• Expert ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions

• Ability to accept direction and feedback, as well as tolerate and manage stress

• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day

• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s):         ☒ Indoor/Office    ☐ Community      ☐ Facilities/Security                       ☐ Outdoor Exposure

Member/Patient Facing:     ☒ No                        ☐ Telephonic       ☐ In Person

Hazards:  May include, but not limited to, physical, ergonomic, and biological hazards.

Equipment:  General office equipment

Travel:  May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.  Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.