Enrollment Compliance Specialist

About the role

This position handles compliance issues which include new laws, mandates and regulations from DOI and federal government along with the tracking, updating, maintenance and reconciliation of the groups who participate in the Retiree Drug Subsidy. This position will also handle all setup and maintenance on Medicare Secondary Payer. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.

Responsibilities

• Conducts research to determine if member qualifies for Medicare Carveout rates and updates member records to reflect or remove Medicare Carveout rates and RDS eligibility.
• Resubmits any members that should be RDS Eligible if rejected by the Center for Medicare Services.
• Reviews all response files received from CMS and any Error or Absent Reports received from ESI and makes any necessary corrections.
• Reviews and works all reports that need to be resubmitted and/or verified with CMS for Medicare Secondary Payment (MSP).
• Communicates with all areas to ensure accuracy of data between BCBSLA, EDI and CMS.
• Counsels on new compliance issues/problem cases and facilitates meetings with appropriate departments to implement new laws and policies and procedures.
• Coordinates the mass mailing of MSP letters to groups once a year to collect group size and Tax ID numbers to ensure no fines are levied on the company.
• Updates group record to reflect information being provided by the group.
• Reviews and reconciles list of potential members from IT and forwards to the group and account manager requesting validation.
• Reviews and reconciles list of potential members from the group leader and forwards to CMS.
• Researches member records to obtain missing information to ensure records are accurate.
• Contacts group leaders to obtain missing information for Medicare.

Requirements

Nature and Scope: This role does not manage people. This role reports to this job: SUPERVISOR, ENROLLMENT & BILLING. Necessary Contacts: To do this job effectively the incumbent has to be in contact with: CMS, Information Technology, Marketing, Legal, Underwriting, Pharmacy Services, Other Party Liability, Research, Claims Units, Customer Service, MTM, other Benefits Specialists and other departments within BCBSLA as needed, other plans, outside consultants, agents, brokers, group leader and subscribers as needed.

Qualifications

• Education: High School Diploma or equivalent is required. Associate's is preferred.
• Work Experience: 5 years in insurance operations with knowledge of billing, reconciliation and/or collections, compliance, working appealed cases or problem/special cases is required.
• Skills and Abilities: Strong analytical, decision-making, organizational abilities, oral and written communication skills, and interpersonal skills are necessary. Able to identify problems, complex business needs and develop solutions/resolve problems. Must be able to work independently and prioritize multiple responsibilities in order to meet aggressive deadlines. Must have strong collaboration and leadership skills in order to work with employees at higher levels and in meetings to resolve discrepancies. Working knowledge of relevant PC software required. Experience in writing system narratives and specifications and in reviewing completed system tests is preferred. Experience in developing system solutions for membership/enrollment administration preferred. Understanding of insurance laws, PHI, and Facets screens is preferred.

Accountabilities and Essential Functions

• Conducts research to determine if member qualifies for Medicare Carveout rates and updates member records to reflect or remove Medicare Carveout rates and RDS eligibility.
• Resubmits any members that should be RDS Eligible if rejected by the Center for Medicare Services.
• Reviews all response files received from CMS and any Error or Absent Reports received from ESI and makes any necessary corrections.
• Reviews and works all reports that need to be resubmitted and/or verified with CMS for Medicare Secondary Payment (MSP).
• Communicates with all areas to ensure accuracy of data between BCBSLA, EDI and CMS.
• Counsels on new compliance issues/problem cases and facilitates meetings with appropriate departments to implement new laws and policies and procedures.
• Coordinates the mass mailing of MSP letters to groups once a year to collect group size and Tax ID numbers to ensure no fines are levied on the company.
• Updates group record to reflect information being provided by the group.
• Reviews and reconciles list of potential members from IT and forwards to the group and account manager requesting validation.
• Reviews and reconciles list of potential members from the group leader and forwards to CMS.
• Researches member records to obtain missing information to ensure records are accurate.
• Contacts group leaders to obtain missing information for Medicare.