Under the general supervision of the manager, the responsibilities for this position will primarily be the development and refinement of the analysis and reconciliation for member eligibility and payment records. Additionally, this position will ensure the accuracy of the beneficiary files and data submissions to/from CMS/State.

This individual regularly demonstrates personal resiliency in times of changing direction and consistently performs routine daily deliverables independently. He/She must be able to plan, organize, and prioritize work to ensure completion in a timely manner. Additionally, this individual will be expected to support the collaborative efforts within Membership Operations and outside the department. Also, he/she 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

• CMS and State revenue analysis, trending, and reporting
  • Perform transactional tasks, including accurately entering and updating member and enrollment records.
  • Perform operational analysis including reviewing data and information to draw conclusions regarding member transactional trending.
  • Perform monthly reconciliation of both CMS & State data and payment variances.
  • Support financial analysis process by providing error and trending reports in a timely manner.
  • Support the development and refinement of the monthly analysis and reporting process for the following: LIS, ESRD, Hospice, Medicaid, State/county Code (SCC), Out of Area (OOA), etc.
  • Expand knowledge of the monthly payments received by CMS and State.
  • Maintain high compliance levels.
  • Analyze reports (from applications & database), raise questions and research member discrepancies.
  • Identify enhancement opportunities for databases and applications.
  • Work with manager to develop metrics and exhibits.

• Ensure accuracy of Beneficiary data in THP, CMS and State systems
  • Review/research data rejects.
  • Analyze trends; provide reporting.
  • Support root-cause analysis; propose process improvements.
  • Collaborate on implementation of new process reporting.
  • Adjust member records and set sequences in Diamond/Market Prominence -- Special Status Beneficiaries, TROOP, 4Rx, OOA, SCC, COB, MSP, etc.
  • Update Notes/Comments in Diamond/Market Prominence, as required.
  • Process notification letters.

• Participate in monthly Medicare Secondary Payer (MSP) processes
  • Resolve MSP payment and eligibility discrepancies appropriately and timely.
  • Perform MSP file transfers & database updates.
  • Support with operational tasks, as needed.
  • Cross-train teammates on MSP processes.
  • Research &/or create MSP documentation.
  • Anticipate & express ways to efficiently recoup outstanding revenue from CMS.

• Provide input for routine or non-critical issue resolution
  • Contribute to process enhancement opportunities; make proposals and recommendations.
  • Ad-hoc projects, as necessary.
  • Conduct in depth quality checking; identify QC training opportunities and trends.
  • Create/format reports (worksheets, graphs, business documents).
  • Delegate/share work within department to balance workload.

Qualifications - What You Need To Perform The Job

EDUCATION: (minimum education)

• Associates degree; some college preferred.

EXPERIENCE: (experience level required)

• 1-3 years related business experience; Medicaid and Medicare experience preferred.

SKILL REQUIREMENTS: (Include interpersonal skills)

• Significant MS Office skills, with focus on Excel and Access at an intermediate level.
• 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.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R7067

Posted On: Tuesday, September 19, 2023