Job description

Manager Enrollment and Membership-SWHR-CNC

Southwestern Health Resources-Care n Care, (SWHR-CNC), is looking for a qualified candidate to join our team.

If you’re looking for a rewarding career at a patient-centered organization with work-life balance and comprehensive benefits, we want to hear from you.

Southwestern Health Resources (SWHR) is a patient-centered clinically integrated network of 29 hospital locations and more than 5,500 physicians and other clinicians. Formed by Texas Health and UT Southwestern, two of the region’s leading healthcare systems, SWHR delivers nationally preeminent, highest-quality care in 16 counties across North Texas. SWHR is also the parent organization of Care N’ Care Insurance Co., a regional Medicare Advantage Plan serving more than 13,500 members in the region.

The SWHR network includes physicians from UT Southwestern and Texas Health, and independent community primary care and specialty physicians. In partnership, our team implements physician-driven, value-based care strategies to coordinate care for more than 700,000 patients, resulting in lower costs and high-quality care. In 2020, the Centers for Medicare & Medicaid Services released the annual financial and quality results and, based on the report, SWHR is one of the nation’s leading Next Generation Accountable Care Organizations, having saved nearly $120 million since joining the program in 2017.

At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.

Position Highlights

The Manager Enrollment and Membership SWHR CNC is accountable for managing the daily operations of the Enrollment Department including oversight of any external vendors delegated to support enrollment and eligibility functions. This encompasses monitoring all aspects of enrollment and eligibility operations of both internal staff and delegates to ensure meeting production and quality service guarantees and all contractual and regulatory requirements. The position will maintain a focus on accuracy of membership data; compliance with CMS guidance, plan policy, and client contractual requirements; and minimizing member disruption.

• Work location: Southwestern Health Resources Headquarters, Farmers Branch, TX.

Position Duties:

Sets clear expectations for staff and external support vendors related to enrollment and eligibility operations production and quality standards and monitors the performance of both to ensure standards and all service level guarantees are met. Provides leadership with timely reports of claims metrics and key performance indicators.

Develops and maintains all department policies and procedures, desk level procedures, and workflows according to current business, contractual, and regulatory requirements; ensures the adherence to all such guidelines by both internal staff and external support vendors.

Develops and maintains procedures for daily monitoring of all enrollment transactions including Beneficiary Eligibility Queries (BEQs), Daily Transaction Reply Reports (DTRRs), and client eligibility file loads and requests as well as member letters to ensure adherence to plan and regulatory requirements and information tracked by CMS. Produces and tracks audit reports of enrollment transaction and letter accuracy and timeliness, identifies trends in the data requiring intervention, and addresses any needed system, process, or training remediations in a timely fashion.

Oversees reconciliations of membership data to ensure accuracy of the data as well as adherence to CMS guidance, plan policy, and client contractual requirements. This includes Monthly Membership Reports, Plan Payment Reports, Medicaid Status Reports, and other coverage files. Oversees Enrollment Data Validation (EDV) audits. Participates in mock and annual readiness audits, Compliance audits, CMS audits, and client audits. Tracks and trends the results of reconciliations and audits and addresses any needed system, process, or training remediations in a timely fashion.

Monitors all aspects of enrollment application processing end to end from receipt to acceptance and fulfillment materials both with the internal team and external support vendors to ensure timely and accurate processing. Monitors all steps of eligibility data imports and reconciliations for client plan membership maintenance.

Ensures enrollment transactions such as cancellations, disenrollment, reinstatements, and facilitated and auto-facilitated enrollments are processed accurately and timely. Oversees the submission and follow-up of Retroactive Processing Center (RPC) packets. Ensures the accurate identification, reconciliation, and maintenance of member other coverage, CARA status, Qualified Medicare Beneficiary (QMB) status, late enrollment penalties, low-income subsidy status, premium billing and collections, and PCP assignments.

Accurately analyzes and interprets CMS guidance related to enrollment, Part C and D Reporting and Technical Specifications, and Plan Communications User Guides and ensures all downstream organization enrollment reporting and transactions follow guidance. Coordinates all department interactions with Compliance and CMS including systems (ECRS, GENTRAN, MARx, etc.). Coordinates eligibility data interactions and updates with clients.

Manages research and triage of escalated enrollment and eligibility issues and discrepancies. Collaborates with other departments, external vendors, and clients as needed in the timely resolution of all such issues and discrepancies.

Responsible for maintaining all plan member letter templates and fulfillment materials for enrollment transactions, other coverage investigations, premium billing and collections, late enrollment penalties, low-income subsidy status, PCP assignments, and optional supplemental benefits in accordance with CMS guidance and plan policy. Ensures external enrollment and fulfillment vendors utilize only approved templates per directive.

Renders performance reviews and delivers timely, actionable, and meaningful feedback from training, audits, and one-on-one meetings. Responsible for new hire trainings and team refresher or update trainings.

Responsible for department staffing and recruitment to ensure adequate coverage for current and projected work. Provides staff development and growth opportunities. Motivates subordinates, establishes teamwork, and builds employee and team morale. Performs other duties as assigned.

Education
Bachelor's Degree Business Admin, Healthcare Admin, or related field with 5 years experience required. Or, Associate's Degree Business Admin, Healthcare Admin, or related field and 7 years experience in lieu of Bachelor’s degree required. Or, H.S. Diploma or equivalent and 9 years experience in lieu of Bachelor’s degree required

Experience
5 Years Medicare Advantage Enrollment experience to include 2 years of supervisory or leadership experience. (with Bachelor's) required. Or:
7 Years Medicare Advantage Enrollment experience to include 2 years of supervisory or leadership experience (with Associate's) required. Or:
9 Years Medicare Advantage Enrollment experience to include 2 years of supervisory or leadership experience (without Degree) required

Skills
Demonstrated management skills with strong employee development and mentoring skills.
Excellent written and verbal communication skills.
Strong focus on customer service and interpersonal skills.
Strong attention to detail with excellent analytical, problem solving, organizational, and time management skills.
Knowledgeable of CMS enrollment regulations and requirements.
Fully conversant with business operations and system requirements related to health plan enrollment operations.
Working knowledge of health care benefit programs (including commercial and government programs).
Demonstrated knowledge with client benefit plans, benefit plan design, certificates of coverage, and explanations of coverage.
Self-motivated with confident decision-making abilities; able to focus in a fast-paced environment and manage time-sensitive issues and complex projects within deadlines and budget.
Proficient in the Microsoft Office applications Excel, Word, and Outlook with working knowledge of Access and Power Point.
Dynamic presentation skills.

Travel Requirements
Local 20% Travel between SWHR locations as needed to perform assigned duties

Why Southwestern Health Resources

As a Southwestern Health Resources you’ll enjoy: comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Let’s move healthcare forward – together. #IndeedTXHLeadership

Job Type: Full-time

Pay: Up to $114,400.00 per year

Schedule:

• Monday to Friday

Supplemental pay types:

• Bonus pay

Work Location: Hybrid remote in Farmers Branch, TX

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