Health Insurance Eligibility Navigator/Enrollment Counselor Resume Example

Responsible for oversight and management of the county's Medicaid Managed Care Department under the direction of the Medicaid Principal and also acted as the Disability Coordinator for Medicaid and Public Assistance applicants in need of specialized services.

• Helped to design, implement, and maintain protocol to transition 14,000 Medicaid enrollees into a mandatory managed care environment; including managed long-term care
• Actively attended and spoke at stakeholder's meetings with other staff, state representatives, health plans, contractors, and recipients to ensure protocol was equitable, transparent, and smooth
• Worked cohesively with Public Assistance, SNAP, and Child Support Units on client eligibility for benefits and enrollment by devising internal eligibility notification system
• Compiled monthly and quarterly enrollment spreadsheets for Director, health plans and State departments
• Performed new hire department orientation and developed department-specific training manual
• Regularly assisted Medicaid enrollees with health plan benefit questions, provider issues, billing problems, network concerns, complaints and fair hearings
• Routinely negotiated with health plans on members' behalf regarding enrollment, billing, complaints, etc
• As Disability Coordinator, pursued referrals, interviewed applicants and completed forms for those meeting criteria. Obtained medical records, submitted cases for review, and connected client to additional community services

Acted as support staff for utilization review nurses, discharge planners, social workers and charge nurses to fulfill all necessary and related clerical duties for the hospital and patients.

• Provided stat medical record copying for patient transfers by rapidly accessing only necessary documents for patient transfer
• Complied daily patient census data for change-of-shift meetings
• Prepared IPRO/Medicare letters for patients meeting alternate-level-of care criteria and dispensed letters according to regulations
• Data-entered patient medical diagnoses, symptomatology, and status for Utilization Review nurses and submitted to insurance payors for continued stay approval
• Typed patient claim denial rebuttals and resubmitted with medical evidence to insurance payors for reconsideration
• Canvased and tabulated bed availability for nursing and adult homes on weekly basis for Discharge Planners
• Faxed PRI data to nursing homes for patients in need of placement

Assisted in the design, support and growth of spouse's successful high-end rustic furniture business.

• Implemented organized systems for payment collections, AP/AR, deposits, petty cash and recordkeeping
• Made quarterly payments for self-employment tax to IRS
• Accepted customer payments, made receipts, completed show contracts, ordered office & shop supplies
• Answered phones, took messages, sent and returned emails
• Helped design marketing materials, postcards, flyers, and negotiated with printers
• Maintained business calendar for furniture fairs, craft shows, client in-home installations
• Attended shows and marketed product