Job Description Summary

This position reports to the Supervisor of Enrollment & Eligibility and is expected to carry an appropriate production workload which will include special handle accounts, performing full billing reconciliations when our group’s terminate health coverage as well as performing the standard day to day tasks associated with being an eligibility specialist. Perform enrollment and billing functions necessary to maintain Covered California for Small Business (CCSB) accounts on Health Care Processing System (HCPS).

Qualifications

• BA/BS degree in accounting, finance, or business related field preferred, plus five (5) to seven (7) years of Accounting/Business experience with knowledge of generally accepted accounting procedures, analytical abilities or equivalent combination of education and experience.
• Four (4) years’ experience as Eligibility Specialist I & II or equivalent background is preferred.
• Advanced skills in establishing priorities, multi-tasking, time management, and ability to work independently with minimal supervision in a team environment.
• Expert knowledge of generally accepted Health Care Eligibility and Billing procedures as well as Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California-COBRA, Multiple Employer Welfare Arrangement (MEWA) and Employee Retirement Income Security Act (ERISA) legislation.
• Advanced computer experience with Microsoft Office Suite: Word, Excel, Visio, Power Point, and Outlook.
• Advanced experience providing Customer Service to a variety of client contacts via email and telephone.
• Ability to research and resolve technical issues and/or client problems as they arise with minimal direction.
• Excellent written and oral communication skills to include modern business communications (e.g. Microsoft Suite, emailing, skype), formatting of professional letters, reports and phone etiquette.
• Advanced knowledge of health insurance operations and industry.
• Fluent in Spanish, both verbal and written a plus.
• Ability to work required overtime as needed.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties And Responsibilities

Eligibility Maintenance

• Maintain Eligibility and Billing for CCSB accounts as assigned including clients that submit eligibility electronically.
• Review manual and/or (adds, changes, terminations) in HCPS as received from the client or internal sources in accordance to Participation Agreements, Employer Policy Statement, Eligibility Guidelines and/or Summary Plan Descriptions.
• Produce electronic spreadsheets and/or reports for audit and processing purposes.
• Perform full reconciliations on accounts in order to confirm that the group is in compliance.
• Research and correct cash application issues in HCPS. Determine/correct out of balance ledger items on accounts. Contact clients to explain and to resolve billing/payment discrepancies. Verify/authorize refunds for terminations and/or overpayments.

Customer Service

• Maintain a business relationship with the group contact, handle escalations that arise with the group, processing the groups EDI (electronic data interchange) files, handling all manual adjustments and billing issues for the special handle account and any other issues that may arise.
• Provide timely and effective Customer Service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their account.
• Interface effectively with internal departments and external vendors, brokers or other business contacts to coordinate interrelated activities and to resolve eligibility and/or billing issues as they arise.