GENERAL DESCRIPTION:
Responsible for analyzing and assessing prospects' eligibility for the Medicare Advantage Programs administered by the company. This assessment will be based on the eligibility rules and policies established by CMS (Center for Medicare and Medicaid Services), Chapters 2 and 3 of the Managed Care Manual, ASES (Puerto Rico Health Services Administration), the company, and any other regulatory agencies.
ESSENTIAL FUNCTIONS:
Receiving and processing applications for Enrollment, Disenrollment, Cancellation, and Product Changes within defined timeframes.
Evaluating and analyzing enrollment documents to ensure compliance with state, federal, and business regulations.
Determining prospect eligibility in CMS and ASES systems, entering or correcting data in company applications systems, and determining applicable eligibility periods.
Identifying cases with missing information, initiating the returns process, and notifying the customer and relevant departments.
Validating reports of cases awaiting information to ensure timely processing in compliance with federal regulations.
Ensuring that all processed or denied cases have appropriate notification letters within established periods.
Following the OFA unsubscribe process as required, including analyzing and evaluating OFA disenrollment or cancellation requests to generate the applicable letter within established times.
Monitoring, analyzing, and documenting cases under the Late Enrollment Penalty (LEP) process.
Providing information and recommendations for action on cases referred related to enrollment and disenrollment processes.
Coordinating and approving the sending of Notification Letters resulting from the PCP (Primary Care Provider) Transfer process.
Analyzing Capitation and Capitation Adjustment Report rejections referred to the Finance department, making necessary adjustments in applicable systems, and reviewing and correcting cases to prevent errors in Capitation payments.
Working on PCP changes referred to by the Service Areas and Premium Management in the PMHS and Voyager systems, as per the company-approved IPA PCP assignment rules.
Reconciling PCP changes received through CRM in PMHS and Voyager systems and making corrections if discrepancies are identified.
Responding within established time to service requests referred by different departments through managed distribution lists in the unit.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and experience
: Associate degree or 60 university credits or equivalent to two (2) years of studies with minimum of six (6) months to one (1) year of experience in group and individual enrollment processes, preferably in the Health Insurance Industry.
Certifications / Licenses:
N/A.
Other:
Experience in advantage products is preferred.
Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Basic (comprehensive, writing and verbal)
TPIS is an Equal Opportunity Employer (EEO Employer / Affirmative Action for Females / Disabled / Veterans). We comply with all Federal, State and Local laws regarding nondiscrimination.
Job Type: Full-time
Pay: From $12.00 per hour
Expected hours: 38.5 per week
Work Location: In person
