Responsible for various functions related to receipt, transmission, translation and maintenance of electronic eligibility data.
Process all health plan electronic eligibility files (Full and Activity) to update System membership on a monthly basis.
Review results of database updates from various electronic sources and take corrective actions if needed.
Coordinate with health plans to ensure timely submission of monthly eligibility files and ensure that file specs are current.
Perform all crosswalk table updates and database maintenance related to electronic data interchange to ensure accurate eligibility, correct claims and capitation payments.
Take corrective actions determined by review of system (exception, recon and adhock) reports to ensure system data integrity.
Interact with various internal and external departments such as:
Configuration - (to ensure that new contracted providers are configured in System).
Claims Dept. (to ensure that dates of service are verified for claims.
Information Systems – (to ensure that EDI Process is updated and accurate.
Health Plans- (to ensure that eligibility files are submitted monthly and on time.
Responsible for Data Encryption, Decryption and downloading eligibility data from internet or FTP sites, to make Diamond eligibility updates. Perform other duties as assigned, including (Level 1) if needed.
- 2-3 Years experience in HMO or related entities with eligibility system applications.
- 1 Year experience in System Eligibility Uploads, or equivalent.
- 1 year experience in HMO/PPO/Medicare in eligibility maintenance
North American Medical Management, California, Inc. (NAMM) develops and manages provider networks, offering a full range of services to...