The Enrollment and Eligibility Specialist is responsible for ensuring the integrity; the accuracy of consumer enrollment information, and benefit eligibility for Cardinal Innovations Healthcare Solutions (“Cardinal Innovations”).
The Enrollment and Eligibility Specialist is responsible for (though not limited to):
Enrollment integrity –
Employee reviews consumer enrollment information submitted by Network Providers to ensure the information is sufficient and accurate. Employee will provide technical assistance to providers and assist them to research inaccuracies and conflicting information.
Eligibility Monitoring –
Employee monitors Integrated Payment and Reporting System (IPRS) and Medicaid system information to assure Cardinal Innovations compliance with state requirements for consumer eligibility and enrollment data. Employee accesses the Medicaid and state systems to verify initial and continued eligibility for care managers and access staff completing authorizations. Employee will also research “kick-outs” and denials from these systems and ensure corrections are completed. Employee will work closely with other Cardinal Innovations’ departments including Care Coordination Department, DD Utilization Management, and the Medicaid Project Manager to ensure Cardinal Innovations consumer eligibility is monitored and maintained.
IPRS Compliance –
Employee will participate in identified meetings, calls, and/or conferences to maintain a high level of competence about the state’s IPRS system. Employee will keep abreast of any changes to the IPRS system requirements and state target populations. Employee will assist with training of internal staff and providers, as needed.
Committees and Meetings –
Employee will attend meetings as needed, to stay informed of changes in departmental, agency, state, federal, and division requirements.
Desired Skills and Education
The employee will need to gain a thorough knowledge of the Cardinal Innovations’ system and other state and federal systems. Employee must gain knowledge of Cardinal Innovations policy, procedures, and processes in the performance of the agencies business, and an understanding of the global and specific operations within Clinical Operations. Must have the ability to analyze and evaluate eligibility records and to apply established standards, regulations, and laws to specific operating problems. Ability to establish and maintain effective working relationship with all levels of staff and provider organizations as well as have knowledge of cultural awareness, differences, the ability and sensitivity to work with a diverse population are required. The employee must be able to communicate effectively and professionally, both verbally and written.
High school graduate with three years of medical records experience preferably in a mental health/substance abuse/developmental disability setting; or equivalent combination of education, experience, and training.
This is an office-based position which primarily occurs during normal business hours. Cardinal Innovations reserve the right to call upon this employee during non-business hours, as needed, to meet the demands of the position. Minimal travel may also be required.
Cardinal Innovations is North Carolina’s largest Managed Care Organization providing Medicaid managed care and state-funded behavioral health plans. Our mission is to enhance the health and well-being of individuals and their families by creating and managing quality healthcare solutions for those who depend on the public system for care. Our plans reflect the uniqueness of our local communities and are capable of making continual adjustments and improvements to meet the changing needs and priorities of our clients. Cardinal Innovations values the contribution of all stakeholders, and our businesses are based on the principles of respect, collaboration, and mutual accountability.
Cardinal Innovations is an Equal Opportunity Employer. Visit our website at www.cardinalinnovations.org to view all vacant positions and apply on line.
Cardinal Innovations Healthcare Solutions - 23 months ago
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