Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Enrollment, Fulfillment, & Billing Senior Quality Specialist is responsible for ensuring the health plan's continuous compliance with all CMS (Centers for Medicare & Medicaid Services) enrollment, disenrollment, fulfillment, and premium billing regulations by conducting critical audits, managing regulatory submissions, and validating internal controls. • Conduct comprehensive member enrollment audits to ensure accuracy and compliance with CMS regulations, plan policies, and standard operating procedures. • Verify the integrity of enrollment data, election periods, and eligibility criteria for Medicare Advantage and/or Part D members. • Identify and report discrepancies or non-compliance issues found during audits to management and relevant teams for timely remediation. • Perform Enrollment and Disenrollment Validation (EDV) audits as required by CMS. • Conduct daily, monthly and routine audits. • Review, process, and validate Medicare Advantage (MA) and Part D enrollment applications received via various channels (online, mail, phone) to ensure completeness and compliance with CMS regulations. • Enter Service Request ticket for correcting LTC assignments, Facility Change Assignments and other tickets as needed. • Track and reply to all email within the Enrollment Shared email box. • Manage and resolve enrollment discrepancies, including Low-Income Subsidy (LIS) conflicts, entitlement issues, and late enrollment penalties (LEPs). • Analyze and resolve complex member premium billing issues, including retroactive adjustments, payment discrepancies, and subsidy reconciliation. • Process and document member premium refunds accurately and promptly, adhering to regulatory timelines and internal controls. • Maintain detailed records of all billing adjustments and refunds for auditing and financial reporting purposes. • Perform quality assurance (QA) reviews on mandated regulatory documents, forms, and communications (e.g., ANOC, EOC, LIS notices) to ensure 100% accuracy, proper formatting, and compliance with CMS requirements. • Serve as a subject matter expert on CMS enrollment and billing mandatory letters, ensuring content accuracy for both the model language and the programming specification based on letter type and member level scenarios. • Update letter matrix with all letters and programming specification year over year. • Track and manage defects identified during testing, ensuring timely resolution before system deployments. • Work independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations. • Participate in any projects and/or daily tasks as assigned. Qualifications • High school diploma or general education degree (GED) required. • Associates degree preferred. • An equivalent combination of education, training, and experience. • 5 years of healthcare experience required. • Industry knowledge specific to the market served by the Health Plan - managed health care. • Ability to demonstrate and act on an understanding of the collective concerns of internal and external customers. • Demonstrates an understanding of how the parts of a problem are related and interact to create an outcome. • Displays effective problem-solving skills, including the ability to resolve conflicts, troubleshoot issues and respond quickly to any situation. • Must be customer focused, including displaying behaviors such as follow-through and courtesy. • Ability to communicate effectively and be adaptable. • Excellent oral and written communication skills. • Able to read and interpret documents and calculate figures and amounts. • Proficient in MS Office with basic computer and keyboarding skills. Requirements • Ability to work as a telecommuter. • Ability to work some occasional evenings/weekends. Apply tot his job