Membership Operations Specialist

Job Summary:

The Membership Eligibility Specialist (Membership Operations Specialist) plays a vital role in ensuring accurate and timely Medicaid eligibility verification and payment reconciliation for members. This position requires meticulous attention to detail, strong analytical skills, and the ability to navigate various systems and data sources. This role will work closely with internal teams to ensure compliance with all applicable regulations and contract requirements.

Supervisory Responsibilities:

This position has no direct supervisory responsibilities.

Duties/Responsibilities:

• Eligibility Verification: Perform monthly Medicaid eligibility revalidation checks for Texas D-SNP members. This includes reviewing eligibility responses from state eligibility systems (via Change Healthcare integration and Orinoco), conducting manual portal checks using the Client Portal and TexMed Connect, interpreting eligibility codes, and documenting findings accurately.
• Eligibility Research: Investigate and resolve eligibility discrepancies using state Medicaid eligibility portals and other available resources. This includes verifying member information such as Medicaid ID, name, and date of birth.
• Disenrollment Processing: Manage disenrollment actions for members who lose Medicaid eligibility, ensuring timely processing of Exhibit 32 and 33 notices and transactions to CMS.
• Payment Reconciliation: Conduct monthly reconciliation of capitated payments against member Medicaid eligibility. Analyze discrepancies and identify root causes of over/under payments in collaboration with internal team.
• Documentation and Reporting: Maintain accurate records of eligibility verification and payment reconciliation activities. Flag and escalate any discrepancies or issues to the appropriate internal team members.
• Collaboration: Work closely with internal team to ensure seamless execution of eligibility and payment processes.
• Compliance: Adhere to all applicable state and federal regulations, as well as internal policies and procedures.
• Perform other duties as assigned.

Qualifications

Required Skills/Abilities:

• Excellent analytical, problem-solving, and communication skills.
• Ability to work independently and as part of a team.
• Additional Skills (Preferred): Experience with Medicare Advantage plans, particularly D-SNPs.
• Familiarity with medical terminology and coding.

Education and Experience:

• High School Diploma or equivalent required; Associate's or Bachelor's degree preferred.
• 1+ years of experience in healthcare administration, eligibility verification, or a related field.
• Strong knowledge of Medicaid eligibility rules and regulations in Texas.
• Proficiency in navigating state Medicaid eligibility portals (Texas Medicaid Client Portal, TexMed Connect).
• Experience with healthcare data systems (e.g., Orinoco, Change Healthcare) preferred.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift to 15 pounds at a time.