Manager Membership & Eligibility

OverviewManages the day to day operations of the VNS Health Plans Membership and Eligibility Unit (MEU) functions related to enrollment and disenrollment activities, member premium billing/collections, and prescription drug event reconciliation activities for all VNS Health Plans Medicare product lines and the Fully Integrated Dual Advantage (FIDA) plan. Supervises Third Party Administrator (TPA) Enrollment/Reconciliation/Billing entities and Third Party vendors to ensure smooth transitions of data transfers. Monitors enrollment processing activities to ensure compliance to Center for Medicare and Medicaid Services (CMS) and State Department of Health (SDOH) guidelines and plan's enrollment contractual agreements. Develops and implements internal control procedures to ensure efficient performance of all membership and eligibility functions. Works under general direction.

Compensation Range:$93,400.00 - $116,800.00 Annual

• Oversees enrollment process for Medicare applications from point of receipt to final determination. Reviews system file transfers between external/internal agents, VNS Health Plans, NYS DOH Medicaid System (EMEDNY) and TPA to ensure acceptance and accuracy of data. Identifies problems and issues and works with staff and vendors on resolutions.
• Manages and develops reconciliation processes necessary to oversee the TPA membership processing activities. Reviews various membership reports in order to determine membership changes, census and growth. Performs ongoing audits of membership data maintained by TPA in order to confirm adherence to CMS guidelines.
• Oversees various audits by reviewing and ensuring proper documentation is assembled and received by the auditor in a timely manner. Works with the auditors to provide background information on our workflows, membership data and various files that comply to CMS rules and regulations. Identifies and addresses issues/areas that can be improved to achieve a better outcome and overall star rating.
• Analyzes CMS and State membership reports (Transaction Reply Report (TRR), Monthly Membership Reports (MMR), Maximus, State rosters , etc.) to ensure membership eligibility data is updated and captured in the various membership systems and membership reporting.
• Monitors communication between MEU Staff, other internal departmental staff, TPA, sales vendor and provider vendors to ensure member eligibility requests/transactions are appropriately handled and completed.
• Reviews monthly payment reports from CMS to confirm receipt of premium payment for active members and completion of retroactive adjustments. Reconciles CMS payment census with plan census and resolves discrepancies. Reviews monthly Attestation Certification prepared by TPA and works with them to finalize report. Advises VNS Health Plans Finance of any reason for holding the submission of the Monthly Attestation Certification to CMS.
• Oversees various processes necessary to confirm that members maintain eligibility criteria. Monitors monthly Medicaid eligibility validations, out of area reporting and timeframes, loss of Medicare, etc. and ensures that staff and TPA take the appropriate actions when members become ineligible for continuous enrollment. Assures CMS compliance and adherence to policies and procedures.
• Oversees processes related to Late Enrollment Penalty (LEP), Coordination of Benefits (COB), Employer Subsidy, Request for Additional Information (RFI) and Retroactive Processing. Monitors compliance to CMS requirements regarding applicant/member correspondence, notification and/or timeframes.
• Reviews and assists with the development and distribution of membership materials, including marketing materials, letters and other direct communications to members. Ensures compliance with governmental regulations in this area.
• Monitors premium billing to members for Medicare Part D. Analyzes monthly billing financials and works reports (Billing, Accounts Receivable, etc. for Social Security Deduction (SSA), Billing Statement and Automatic Clearing House (ACH) methods). Recommends write-offs and refunds as appropriate. Works with TPA, staff and VNS Health Accounts Payable to request payments as necessary.
• Reviews Medicare Part D Prescription Drug Event Reports and sees that staff, other MA/PD plans, and Pharmacy Benefit Manager (PBM) work to resolve edits and errors. Identifies, tracks and trends issues and alerts PBM as necessary, assist with finding resolutions as deemed appropriate.
• Reviews Medicare Part D True Out of Pocket (TrOOP) Reports received from Pharmacy Network Vendor and CMS TrOOP Facilitator. Recommends and/or makes eligibility corrections as needed and acts as liaison to the various entities. Assures CMS compliance to TrOOP Facilitator requests.
• Analyzes Plan to Plan Reconciliation Reports and determines VNS Health Plan's accounts payables (AP) and accounts receivables (AR). Ensures compliance to CMS payment requirements to MA/PD plans. Makes sure accounts receivables are collected. Prepares financial reports to track and trend AR and AP.
• Reviews monthly Sales Agents (Internal and External) Commissions Reports and confirms accuracy prior to submission to Human Resources.
• Tracks and reports third party vendor issues related to MEU responsibilities and makes suggestions for improvements.
• Reviews enrollment/disenrollment and retroactive processing invoices from TPA for accuracy and makes recommendations about payments.
• Acts as liaison to Third Party Vendors regarding membership eligibility.
• Monitors, develops, evaluates and implements current, new and/or revised policies and procedures designed to improve efficiency of department business operations.
• Maintains up-to-date knowledge of Medicare and Medicaid policies to ensure compliance with directives and regulations as they relate to Medicare and FIDA enrollment and provides educational guidance to support staff.
• Performs all duties inherent in a managerial role, including monitoring and evaluating the productivity of assigned staff. Works with staff to facilitate their professional growth and development.
• Participates in special projects and performs other duties as assigned.

QualificationsEducation:

Bachelor's Degree in Business Administration, Health Administration, or related discipline required Master's Degree in Business Administration or Health Administration preferred

Work Experience:

Minimum five years direct supervision and management of staff, preferably in a health care environment required Demonstrated knowledge of enrollment operations, with strong knowledge of Medicare and working knowledge of Medicaid. Has understanding of an effective and efficient reconciliation system and some knowledge of financial operations. Advanced proficiency with Excel, Access and Word software applications required Effective oral, written and interpersonal communication skills required

CAREERS AT VNS Health

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