Enrollment Validation Specialist - Denver Health Medical Plan (Weekly On Site Requirement)

At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. Our values: Respect | Belonging | Accountability | Transparency.

This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Must live in Colorado.

About the role

Under minimal supervision, contributes to the daily operations and analysis of enrollment related activities for all lines of business for the Denver Health Medical Plan. Compiles and analyzes reports for fallout and coordination of benefits, MedImpact, 834s. Reconciles complex sets of data received in order to validate reporting. Works and collaborates directly with the manager, and other partners such as all levels of management and employees, plan members, external consultants, DHAA, State and Federal entities and other community organizations to improve enrollment process and optimization of systems.

Responsibilities

• Collaborates with strategic initiatives and operations for the Health Plan Enrollment team (10%)
• Works independently and with other Managed Care Departments to compile reports, attestations, and other submissions to submit to the State and CMS/HPMS (10%)
• Collaborates with other departments to compile, analyze and ensure the accuracy of data and documentation for internal and external compliance audits (10%)
• Development and adherence to enrollment processes, policies and procedures (10%)
• Resolve claim concerns or member access issues related to enrollment and coordination of benefits (5%)
• Reconciles complex sets of data received from CMS or the State in order to validate reporting, financial reconciliation, and encounter submissions to align with established goals and metrics (5%)
• Actively identifies problems and opportunities for improvement; identifies appropriate solutions and involves others in the implementation process (5%)
• Validate member enrollment and disenrollment (5%)
• Partner with other departments to include Claims, Pharmacy, and IS in developing solutions as issues arise (5%)
• Ensure compliance with all applicable Federal and State rules and regulations, validating contractual enrollment requirements are reflected in plan enrollment system (5%)
• Analyze and reconcile data including claims, 834, and 820 files for trends and discrepancies, reporting any operational deficiencies to the Manager (5%)
• Load electronic eligibility files and capitation files in 834 and 820 format (5%)
• Monitor and assess electronic file uploads to ensure data quality (5%)
• Analyze Special Enrollment documentation provided from members to determine Commercial coverage eligibility (5%)
• Identify issues with enrollment, trend and perform root cause analysis for all lines of business (5%)
• Utilize various data analysis tools such as Tableau, Excel and SQL to create reports for department and organizational use (5%)

Requirements

• Bachelor's degree required — OR — 4 additional relevant years of experience in lieu of a degree
• Four years of direct health care experience with a specific emphasis on Government Health Program operations, regulatory issues, policy development, or compliance

Skills

• Extensive knowledge of managed care, Medicare, Medicaid and CHP+ eligibility and enrollment requirements, rules, and processes
• Knowledge of Federal and Colorado State statutes, legislative initiatives and regulations, as well as Federal, State and local policies
• Ability to develop data requirements and work with operations teams and groups to extract, organize and analyze data and trends
• Ability to define problems: collect data, establish facts and draw valid conclusions to implement solutions
• Skilled in analytical thinking, problem solving, and process improvement
• Critical thinking, strong written and verbal communication skills, and the ability to effectively interact within a team
• Proficiency in Microsoft Office Suite, Tableau, and Health Plan Management Software involving Claims, Enrollment systems, and Government Data Portals

Pay

$67,300.00 - $101,000.00 / yr

Benefits

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
• 100% paid parental leave up to 6 weeks
• Immediate eligibility for retirement plans with employer contribution up to 9.5%
• Generous medical, dental, vision plans in addition to employer paid disability and life insurance
• Comprehensive well-being programs including on-site employee fitness center and nationally recognized RESTORE Center
• Free RTD EcoPass (public transportation)
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer + free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation. As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.