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Ensures Medicaid members receive timely redetermination notices in accordance with State processes and Contract requirements. Tracks and maintains member enrollment, eligibility and program rosters, including members in Medicaid Pending status and members within 60 days post loss of Medicaid eligibility (the SIXT period). Develops and manages the process for tracking redetermination and documenting the assistance provided by the Plan. Collaborates with the primary care manager to assist members in completing the DCF redetermination process to avoid loss of eligibility. Serves as Subject Matter Expert on Medicaid eligibility and level of care redetermination processes.
Track and review member eligibility timelines and requirements to maintain Medicaid eligibility, including members in Medicaid Pending or SIXT status.
Work with primary care managers to provide Medicaid and level of care redetermination assistance for members.
Conduct mail and telephonic outreach to assist members/family with processing Medicaid recertification to ensure understanding of eligibility requirements to maintain continuous eligibility in the program.
Tracks member product (i.e. MLTC, MMA, SMI, etc) level of care redetermination timelines based on State requirements.
Coordinates enrollment/disenrollment/eligibility activities with State agencies, as appropriate.
Reviews and analyzes all State agency reports/rosters/premium files and compares to eligibility files to validate eligibility and intervene when discrepancies are identified.
Proactively troubleshoot and take initiative to assure accuracy of outgoing/incoming eligibility information and provide solutions to issues with the data. Assist in identifying the extent and reason for discrepancies and assist in developing processes to correct.
Understand the CMS and State Systems in order to verify enrollment and eligibility, download and track files.
Serves as subject matter expert on Medicaid and assigned product line (i.e. MMA, MLTC, SMI, etc) level of care redetermination processes and timelines based on Contract requirements.
Serves as a mentor other team members.
Ensures routine and ad-hoc enrollment and eligibility reports are completed and submitted accurately and timely.
Adhere to all HIPPA standards and confidentiality requirements.
Additional duties as assigned.
Additional Responsibilities:Candidate Education:
Preferred A Bachelor's Degree in a related field
Required 2 years of experience in Experience in customer service, enrollment or operations in human services or a health care setting
Intermediate Demonstrated customer service skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Other Familiarity with Medicaid/Medicare eligibility processes, practices, procedures and technology
Intermediate Other Knowledge of Medicaid/Medicare enrollment and reporting practices
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to represent the company with external constituents
Licenses and Certifications: A license in one of the following is required: Technical Skills: