Job Description

The Enrollment and Eligibility Specialist (EES) is an integral member of the team, providing direct support to our members and care teams to increase member retention. The EES serves as the subject matter expert (SME) in the enrollment and eligibility process of his/her assigned market with the primary goal of proactively identifying state, health plan and/or AbsoluteCare eligibility changes that may impact member enrollment in our programs. The EES is responsible for proactively identifying and addressing eligibility changes, assisting members in maintaining Medicaid certification, supporting members who lose Medicaid eligibility in the recertification process, and coordinating with the care teams for disenrollment as appropriate.

The EES is the center SME and point of contact for questions related to eligibility status, and provides information, guidance and support to the local team and members to prevent lapses in coverage and increase member retention. The EES may also support members transitioning out of AbsoluteCare upon changes in eligibility status, e.g., PCP changes, health plan changes, ineligibility, or transitions to Medicare. The EES is the subject matter expert on state eligibility requirements for Medicaid, Medicare, other programs, or health plan requirements that could impact eligibility per each contracted payer.

The ES promotes the mission, vision, and values of AbsoluteCare and extends 5-star customer service in all interactions. The is a hybrid position with both in office and remote work.

Duties and Responsibilities

• Confirm patient eligibility and PCP assignment daily for all provider visits scheduled
• Coordinate with member relations for PCP assignment discrepancies
• Maintain a knowledge of assigned state and/or federal eligibility requirements for Medicaid and/or Medicare beneficiaries
• Maintain a knowledge of eligibility requirements per each assigned payer contract
• Use data and reporting to identify members with upcoming eligibility termination
• Directly assist members with the recertification process
• Understand AbsoluteCare enrollment processes and how enrollment into other programs may impact enrollment with AbsoluteCare
• Assist members directly as the first point of contact when there is a change in eligibility, including providing information on eligibility processes, assisting members with completing and uploading required documents to maintain Medicaid/Medicare eligibility into State portals, following up with members to ensure recertification processes are completed timely
• As appropriate, coordinate with the member’s primary care manager to assist with reminding members to recertify or to determine next steps for disenrollment
• Maintain access and serve as a SME on assigned state eligibility and payer eligibility websites
• Work closely with member relations and care teams to coordinate timely discharges and support member transitions out of AbsoluteCare, as appropriate

Minimum Qualifications

• High School diploma required; Bachelor’s degree preferred
• 1+ years with Medicaid, Medicare, and/or health plan coverage and eligibility requirements, e.g., state or federal Medicare/Medicaid agency or health plan eligibility experience
• 1+ years’ experience in serving the needs of complex populations in a health care setting and working directly with members
• Good computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Good written and oral communication skills and the ability to work closely with co-workers, patients, family members, and State agencies.

Direct reports

None