Reconciliation Specialist (Onsite 3 Days/Week)

Center for Medicaid and Medicaid Services (CMS), Department of Health (DOH), Local Department of Social Services (LDSS)/Human Resources Administration (HRA), Maximus), reports prepared by Third Party Administrator (TPA) and various VNS Health Plans department staff. Reviews Membership Files to validate adherence to processing timeframes and documentation in the appropriate membership systems (Facets, Salesforce, Pre-enrollment browser, Mainframe) to ensure timeliness of applicant and member correspondences.

Overview: Provides analytical support to VNS Health Plans Membership and Eligibility Department in order to ensure internal controls of enrollment, disenrollment, and billing processes for all VNS Health Plans product lines. Reconciles monthly membership and oversees the Third Party Administrator's (TPA) processing methods of enrollment application receipts and membership and revenue reconciliation. Works under general supervision. Responsibilities:

What We Provide

• Referral bonus opportunities     
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays   
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability    
• Employer-matched 401k retirement saving program and opportunity for both pre- and post-tax contributions 
• Personal and financial wellness programs    
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care and commuter transit program    
• Generous tuition reimbursement for qualifying degrees   
• Opportunities for professional growth, career advancement and CEU credits 

What You Will Do 

• Reviews and analyzes all membership transactions, including enrollment, disenrollment and cancellations for VNS Health Plans Products through various Governmental Agency produced reports (e.g. Center for Medicaid and Medicaid Services (CMS), Department of Health (DOH), Local Department of Social Services (LDSS)/Human Resources Administration (HRA), Maximus), reports prepared by Third Party Administrator (TPA) and various VNS Health Plans department staff.
• Conducts ongoing meetings with TPA, LDSS/HRA, Maximus or VNS Health Plans staff to review results and discuss important membership topics.
• Prepares reports for review by management staff indicating a summary of membership activities and status of plan membership.
• Monitors processing of membership activities in order to confirm compliance with CMS and DOH guidance.
• Reviews Membership Files to validate adherence to processing timeframes and documentation in the appropriate membership systems (Facets, Salesforce, Pre-enrollment browser, Mainframe) to ensure timeliness of applicant and member correspondences.
• Designs performance indicator reports based on analyses of compliance findings.
• Makes recommendations to change workflows and Policies & Procedures to improve performance as needed. Implements changes upon approval.
• Acts as liaison between VNS Health Plans staff, LDSS/HRA and Maximus to confirm that enrollment applications and disenrollment requests receive final determination.
• Ensures timeliness of enrollment and disenrollment processing, adherence to established policies & procedures and DOH guidance. Apprises appropriate staff of procedural changes.
• Works closely with TPA,LDSS/HRA and Maximus to resolve pending enrollment application issues, disenrollment issues and member maintenance/eligibility issues (i.e. Medicaid status, state and county code discrepancies, Medicare status and changes, etc.). Follows up with departmental staff or members for any required information or documentation in an effort to avoid unnecessary or inappropriate denials.
• Takes lead in fostering good working relations with Maximus, LDSS/HRA and TPA staff.
• Performs reconciliation analysis of member eligibility data transfers between TPA and various third party vendors on a daily, weekly or monthly basis to ensure vendor systems are updated accordingly. Works with all parties to address and resolve discrepancies to reduce financial and compliance risks to the plan.
• Monitors Medicare Part D Reconciliation activities related to Prescription Drug Event data and Plan to Plan Reconciliation.
• Conducts monthly analyses of VNS Health Plans enrollment and disenrollment outcomes and prepares various census and membership reports.
• Reviews and analyzes CMS Monthly Membership Reports that disclose membership and payment amounts.
• Works closely with TPA in reviewing CMS payments to plan and researches payment discrepancies. Validates that appropriate payments are received and follows up on any retroactive adjustments. Responsible for alerting MEU and Finance Leadership Teams of any potential problems regarding revenue expectations.
• Prepares various Accounts Receivable reports and reviews Attestation Summary Reports from TPA. Conducts comparative analyses.
• Oversees monthly premium bill process for Medicare product. Reviews billing reports and transactions posted to the general ledger. Applies payments to appropriate accounts and directs TPA in write off processing. Ensures accuracy and compliance for all billing processes.
• Continuously evaluates membership systems (Facets, Pre-enrollment browser, Salesforce) and makes recommendations for improvements.
• Conducts ongoing internal audits with TPA to monitor timeframes are met with membership submissions to CMS and member correspondence mailings. Performance results are tracked on various internal reports and the Online Monitoring Tool (OMT).
• Oversees all external audits (e.g. CMS, Enrollment Data Validation, PDE data, etc.). Provides support as needed to complete throughout the audit process.
• Assists with development and production of membership communications/materials.
• Acts as a resource to Reconciliation Analyst for assistance and guidance. Provides analytical support to MEU management staff.
• Participates in special projects and performs other duties as assigned.

Qualifications:

Education:

• Bachelor's Degree in Finance, Accounting, Business Administration, Health Administration or related discipline or equivalent work experience required

• Master's Degree in Business Administration or Health Administration preferred

Work Experience:

• Minimum five years experience working in a Health Care environment (three years experience for candidates with a Master’s Degree).

• Demonstrated knowledge of operations, with a working knowledge of Medicare and Medicaid.

• Has a keen attention for detail and a very good understanding of an effective and efficient reconciliation system.

• Advanced proficiency with Excel and Word software applications required

• Effective oral, written and interpersonal communication skills required

Pay Range: USD $66,300.00 - USD $72,000.00 /Yr.