***Please note: internal applicants only***
The Accountable Care Department is responsible for managing the Confluence Health Employee Plan, Health Alliance Medicare Advantage Plan and serves as a sub-delegate for Molina Health Care of Washington (Medicaid) ensuring that each patient gets the right care, at the right time, at the right location.
The Accountable Care Enrollment Specialist will be responsible to ensure timely and accurate eligibility of Confluence Health Molina members for the purpose of utilization management, network support, claims processing, and capitation payments, as well as providing customer service functions to providers and members.
1. Responsible to field and timely answer eligibility inquiries regarding Confluence Health Molina Membership for all Stakeholders.
2. Daily loading of the active eligibility file received from Molina to complete New, Termed and Re-enrolled Member updates into the Monument system, reconciling errors.
3. Works with Accountable Care Application Analyst to justify retro additions and terminations to rectify the Capitation Report.
4. Actively monitor and manage duplicate eligibility records to assist in the accuracy of member benefit levels and department reinsurance reporting.
5. Responsible to support Accountable Care Customer Service Representative by taking calls and problem solving Molina claims inquiries, member, and provider concerns.
6. Responsible to rectify Molina out of Area Report, including verifying member address accuracies and ensuring all eligibility systems are updated to match.
7. Responsible to work Newborn eligibility including entering newborn eligibility and tracking payment of birth month capitation.
8. Responsible to work SSI eligibility process and monitor cases through to SSI eligibility determination.
9. Provides timely and professional verbal and written communication keeping multiple parties informed of eligibility inquiry reconciliations.
10. Use sound and fair judgment to resolve eligibility issues that require multi-faceted problem solving and exhaustive research.
11. Responsible to work with Molina Health Care of Washington Provider Specialist to identify members that have a primary insurance and maintain that other insurance information is entered in the monument system.
12. Responsible to create a Confluence Health Molina Eligibility Inquiry Decision Flow Chart.
13. Responsible to triage urgent member moves versus normal eligibility inquiries.
14. Responsible to send letters of eligibility termination to both Members and their Primary Care Provider of record.
15. Other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
· Associates Degree or work history experience.
· 1 year experience providing customer Service in a health care field setting.
· 1 year experience in an office setting possessing intermediate computer knowledge such as MS Office.
· Demonstrated ability to apply knowledge and skills to analyze multi-dimensional issues.
· Demonstrated proficiency in letter writing skills and effective two-way communication.
· Demonstrated ability to drive own productivity, be resourceful and work independently.
· Demonstrated Professionalism.
· Demonstrated ability to use sound judgment.
· Demonstrated ability to work as part of a team, maintaining a positive demeanor during challenge.
· Understands and makes use of the decision-making authority that has been granted.