Eligibility Specialist II

About the Role

This position reports to the Supervisor I, Enrollment and Eligibility. The Eligibility Specialist II processes enrollment and billing functions—both automated and manual—within the company’s system to maintain Western Growers Assurance Trust (WGAT) and Pinnacle Claims Management, Inc. (PCMI) accounts, including groups that submit Electronic Data Interchange (EDI) eligibility. The role provides customer service support to clients by instructing them on correct eligibility management and explaining billing and payment issues, as well as researching and resolving eligibility and billing discrepancies or inquiries.

Responsibilities

• Process all transaction types such as adds, terminations, changes, carrier discrepancies, and other eligibility-related tasks for all lines of business, WGAT, and Pinnacle.
• Review and process manual and/or EDI enrollment transactions (adds, changes, terminations) in HCPS as received from clients or internal sources, adhering to Participation Agreements, Employer Policy Statements, Eligibility Guidelines, and Summary Plan Descriptions.
• Research and correct cash application issues in the company’s processing system. Determine and correct out-of-balance ledger items on accounts.
• Contact clients to explain and resolve billing and payment discrepancies. Verify or authorize refunds for terminations and overpayments.
• Perform full reconciliations on accounts to confirm compliance.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to protect confidential/protected client and enrollee data.
• Meet processing cycle time standards and production due dates set by management.
• Maintain performance in accordance with established quality standards, as measured by audit metrics. Consistently meet or exceed audit score requirements for accuracy, compliance, and service excellence.
• Identify inefficiencies in established processes and suggest solutions to save time, reduce risk, or reduce expenses.
• Create and document Standard Operating Procedures (SOPs).
• Identify, initiate, and implement process improvements and/or innovation.
• Work with clients to facilitate on-time payments for the billed amount.
• Provide timely and effective customer service for requests, inquiries, or issues concerning enrollment and/or billing via phone calls, logging into Genesys, and adhering to the daily phone schedule.
• Interface effectively with internal departments and external vendors, brokers, or other business contacts to coordinate interrelated activities and resolve eligibility and/or billing issues.
• Serve as a representative of Western Growers and PCMI, displaying professionalism, knowledge, customer service, and discretion in all interactions.
• Provide guidance, feedback, and support to new team members with processing and reviewing their phone calls.
• Identify training deficiencies and provide feedback to administration leads.
• Serve as a backup subject matter expert for new employees.
• Demonstrate support and collaboration within the team by offering assistance and providing resources when possible.
• Maintain integrity and transparency in all tasks, aligning with team and organizational goals.
• Hold oneself accountable by taking ownership of actions, decisions, and outcomes.
• Reflect on personal performance regularly, identifying areas for improvement and celebrating successes.
• Commit to continuous learning and growth, seeking feedback and implementing constructive changes.
• Utilize all capabilities to enhance the competitiveness and profitability of members by being curious, planning, and executing work helpfully and collaboratively.
• Maintain an internet speed of 40 MB download and 10 MB upload with a router supporting wired Ethernet.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• Perform all other duties as assigned.

Work Environment

The physical demands and work environment described are representative of those required to perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

• Regularly required to communicate with others.
• Frequently required to move around the office.
• Often required to use tools, objects, and controls.
• The noise level in the work environment is usually moderate.