Membership & Eligibility Representative
Location: Orange, California US
Job Number: 2182
Position Title: Membership & Eligibility Representative
Membership & Eligibility Representative
Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.
By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.
The Membership & Eligibility Representative is responsible for the daily operations of both Eligibility and Membership Department. Provides Alignment Health Plan (AHP) internal departments, employee/partners and contracted providers in obtaining proper eligibility and membership data.
(May include but are not limited to)
- Responsible for the reconciliation of all lines of business, as well as the CMS monthly files.
- Responsible to assist within both areas of membership and eligibility. This includes late enrollment penalty, disenrollments, out of areas, retros, third party submissions etc.
- Responsible for meeting the regulatory compliance in all areas that affect the Eligibility and Membership.
- Answers the incoming phone calls within the goal marks set. Responsible for the daily, weekly, and monthly review and reporting of departmental queue stat reports to include Wrap-Up Code Reports, Resolution Contact Reports, and Agent Availability Reports
- Ongoing clean-up of member data in all lines of business to ensure correct member information is provided to all systems and vendors.
- Meet specific deadlines. Responds to variations in daily workload by assigning tasks priorities according to department policies and standards.
- Ensure daily TRR is validated and all transactions are reviewed.
- Problem-solving process to resolve and/or mitigate those operational issues resulting in negative performance to plan as determined by the established escalation process.
- Will ensure that participation is made in the development and implementation of programs with direct effect towards the eligibility department. Participate in training programs and with the creation of materials for the day-to-day activity that is performed within the department.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Minimum Experience:
- One to three months related experience and/or training; or equivalent combination of education and experience.
- Must have previous member eligibility experience.
- Must have two years’ experience in the health care field.
- High school diploma or general education degree (GED).
- Must be familiar with CMS MMR and TRR files
- Must be familiar with EZCAP systems
- Must be familiar with excel and word
- Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
- Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Strong computer skills.
- Other Skills and Abilities:
- Excellent communication skills.
- Excellent telephone techniques.
- Excellent data entry.
- Strong organizational skills.
- Type 40+ words per minute.
- Experience with 10-key by touch.
- Work Environment
- The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to walk; stand; reach with hands and arms.
- The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Membership & Eligibility Representative
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.