Manager, Customer Service (Enrollment and Reconciliation)
CalOptima - Orange, CA

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The Manager of Enrollment and Reconciliation is responsible for managing the daily operations of the enrollment & reconciliation team within the Customer Service department. This position will interface with staff in Customer Service, other CalOptima departments and external agencies, e.g. Social Services. The team is responsible validation of enrollment information from the State of California for CalOptima Medi-Cal membership, as well as demographic updates and entry of member health network selections, and requests received from other areas. In addition, this position oversees the timely and accurate entry of enrollments, disenrollments and daily maintenance of eligibility for CalOptima’s OneCare – HMO SNP and other programs as appropriate. This position ensures staff are trained in the use of CalOptima’s membership database, in reconciliation of data with daily, weekly, and monthly reports from the Information Services (IS) department and from the Centers for Medicare & Medicaid Services (CMS), as well as the Department of Health Care Services (DHCS). Management oversight also ensures compliance with CMS regulatory requirements for enrollment, disenrollment and eligibility maintenance for CalOptima’s Medicare program(s).

Position Responsibilities
  • Manage staff, projects, and activities in the enrollment and reconciliation area.
  • Work closely with IS and other departments on projects, reporting and audits.
  • Work with IS and imaging vendor to ensure timely entry, storage, and retrieval of member selection forms, and key Medicare program documents.
  • Research and respond verbally and/or through written communication to inquiries from CalOptima staff and external agencies concerning member eligibility and enrollment-related issues.
  • Responsible for accurate and timely processing of all enrollment applications and CMS Transaction Reply Reports for CalOptima’s Medicare program(s) as well as other programs.
  • Manage enrollment specialist escalated issues, research regulations and develop department policies and procedures.
  • Ensure all Medicare and DHCS regulations and timeframes are met.
  • Responsible for meeting all internal and external Key Performance Indicators (KPIs) and reporting results to senior management on a monthly basis.
  • Responsible for the distribution of reports to management and staff.
  • Provide assistance and education to members regarding benefits, health coverage and continuity of care issues as needed.
  • Assist with education/orientation about CalOptima members’ enrollment to beneficiaries and community agencies as needed.
  • Interviewing, selecting and training new staff.
  • Other projects and duties as assigned.
Required Skills
  • Communicate effectively, both verbally and in writing.
  • Bilingual in English/Spanish or English/Vietnamese preferred.
  • Excellent organizational and communication skills.
  • Strong technical skills related to eligibility systems and membership reconciliation.
  • Working knowledge of DHCS and CMS enrollment/disenrollment and membership regulations.
Required Experience

Experience & Education
  • High school diploma or equivalent required.
  • Relevant Bachelor’s degree preferred.
  • 3+ years related experience required.
  • Management experience of Medicare enrollment and reconciliation required.
  • Experience working with CMS contracted vendors and systems, such as Retroactive Processing Contractor, Wipro/InfocrossingMarx, etc. is desired.

Knowledge of:
  • Principles and practices of health care service delivery and managed care, Medicare, Medi-Cal/CalOptima eligibility and benefits.
  • Principles and techniques for effective communication and education to serve diverse social and ethnic groups.
  • Appropriate customer service principles and practices.
  • Working knowledge of Microsoft Excel, Word and Outlook.
  • Strong knowledge of CMS Medicare Modernization Act (MMA), DHCS regulations and HIPAA standards.
  • DHCS and CMS enrollment and disenrollment regulations.

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