Enrollment Data Specialist
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
Position Title: Enrollment Data Specialist
The Enrollment Data Specialist performs operational solutions to optimize membership enrollment and premium billing accuracy and collaborates and supports internal and external customers. This position researches and reconciles systemic eligibility/enrollment or premium billing /payment discrepancies to arrive at a consistently compliant disposition and operates in a fast-paced environment with frequent priority changes. The Enrollment Data Specialist is held responsible for understanding and abiding by State, Federal, and organizational guidelines for various lines of business related to Membership enrollment and reconciliation.
30% Determine Member’s eligibility and process request according to regulatory guidelines. Eligibility Extract and account billing analysis.
20% Performs research and resolves errors/ discrepancies related to transactional data within internal systems
20% Submission of enrollment and eligibility disputes to regulatory entity Completion of internal case inquiries: enrollment and/or billing Reconciliation of accounting and membership data to align with regulatory entity.
10% Processing account refunds
10% Responsible for staying up to date with the latest communications, regulatory requirements, industry best practices, and guidance provided by regulatory entity
10% Actively contributes to achievement of departmental goals, as identified in Department’s annual business plan, including specific departmental process improvement plans and other duties as assigned.
• High School Diploma
• Two (2) years related experience with health insurance, managed care, or customer service.
• Knowledge of eligibility files /premium billing, Medicare preferred.
• (Medicaid/ Chip- with Star kid- familiarity highly preferred.)
• Knowledge of reconciliation and Analysis of reports
• Advanced Experience of Excel- (Pivot tables working knowledge - preferred).
• Microsoft Office (Word, Excel, and Outlook), SQL a plus
Organizational Core Competencies:
All employees are responsible for understanding and demonstrating Community Health Choice core competencies:
• Customer Focus – Sustainability
• Reliability and Dependability – Employee Empowerment
• Honesty & Integrity – Sustainability
• Change Management – Affordability
• Teamwork – Employee Empowerment
• Problem Analysis
• Attention to Detail
• Above Average Verbal
• Exceptional Verbal