Highly professional and meticulous Enrollment Supervisor with comprehensive background in health administration and insurance paperwork/electronic submissions. Exceptional abilities to maintain member confidentiality and accurate bookkeeping. Able to function well independently or as a member of a professional health administrative team.
Highly organized with attention to detail.
Outstanding oral and written communication abilities
Work collaboratively and cooperatively as a team member.
Demonstrate role as a contributor to successful team efforts.
Able to contribute to problem solving, shift priorities as needed.
Capable of taking direction, work independently, and communicate efficiently.
Excellent interpersonal skills in order to communicate and work with staff of all skill and experience levels.
Able to plan outcomes for a work group session and manage group dynamics to effectively reach a positive outcome.
-Supervise day-to-day operations of all aspects of the Member Enrollment Specialists and responsible for overseeing enrollment tasks related to interdepartmental and/or company wide projects.
-Distribution and monitoring of daily exception discrepancies, weekly/monthly reports, Urgent matters and ad-hoc reports for all business lines.
-Conduct quality control on data change per 834 files received, audit files, manual enrollment files and directed action per management.
-Primary liaison between Member Enrollment Analysts and Member Enrollment Specialists.
-Support Enrollment Manager by providing guidance to department staff under the Manager's direction.
-Demonstrate and educate Enrollment procedures to other teams/departments impacted by our actions.
-Conduct appropriate disciplinary actions in accordance to Tufts Health Plan Human Resources policies and products.
-Provide feedback and coaching to Enrollment Specialist via regular one-on-one meetings.
-Substantively represent Enrollment Team in cross-functional meetings as assigned.
-Maintain professional growth and development through self-directed learning activities and involvement in professional, civic, and community organizations and/or activities.
-Perform daily reconciliation of membership data download from the state.
-Run daily membership reports and distribute, via e-mail, to appropriate staff within Network Health.
-Assign NOB numbers to newborns and entered them into CCMS system.
-Research data discrepancies to assist the Senior Database Specialist with production of monthly membership reconciliation reports.
-Respond to inquiries and requests from other departments, e.g., Provider Relations, Customer Service and Claims, regarding member data.
-Establish inter-department workflow and work production timetables.
-Perform related duties as assigned.
-Processed basic and medium-complexity claims received through the returned mail procedure.
-Worked with both internal and external provider representatives to ensure claim payment in a timely and accurate manner.
-Researched missing and/or incomplete data to ensure that denied claims could be adjudicated.
-Triaged incoming mail to appropriate staff within the Claims departments as well throughout the organization.
-Performed logging, research, communication, and resolution tasks within the department's published standards.
-Helped identify systematic problems, reported to management and offered solutions/ideas.
-Processed claims in accordance with Network Health's policies and procedures.
-Investigated and responded providers regarding their claim issues.
-Assisted in developing recommendations for improvements to the claim processing system.
-Interacted with various operational departments to ensure accurate and timely payment of claims.
-Responded to provider calls related to, transportation guidelines, member eligibility, managed care status, prior authorization, pharmacy guidelines and procedures.
-Functioned as front-line contact for all members by responding to high-volume of incoming calls from members and prospective members.
-Provided members with MCO options available to promote member choice within assigned network or managed care providers, using knowledge gained through training and other sources.
-Conducted thorough health care need assessment with members, including existing and anticipated needs of all eligible family members.
-Investigated third party resources and complied with systems and administrative requirements.
-Performed data entry functions to reflect member or provider activity/transactions.
-Facilitated resolution of non-clerical issues related to client and provider compliance/participation according to established polity and protocols.
-Fluent reading /writing Spanish.
-Able to comprehend very few words in Portuguese.
|Skills||Experience||Total Years||Last Used|
|Windows, Mac OSX||Medium||8||Currently|
-Enrollment Software: Xpress Monument
-Healthcare Software: Member Management Utility, CCMS, OnBase, MassEvs, CMS
-Desktop Publishing Software: Photoshop, Illustrator, Premier Pro.
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