Eligibility and Enrollment Specialist

Description

 Life at Healthy Alliance 

At Healthy Alliance, our purpose is to improve health and empower communities facing barriers. Every community has its own needs, affecting the health of those who live, learn, work, and play within them. Our network brings together organizations, big and small, to coordinate and collaborate so that all communities have reliable access to the resources they need. Why? Because every New Yorker deserves the same opportunity to be healthy.  

Designated as the Social Care Network (SCN) Lead Entity for the Capital Region, Central NY, and North Country under New York’s 1115 Waiver Amendment’s SCN & Health-Related Social Needs (HRSN) Program, we are responsible for ensuring that there is a seamless, consistent end-to-end process for screening, navigation, and the delivery of services – including food, housing, and transportation to thousands of Medicaid Members. Transformative in nature, this novel Program will further sustain our vision of cultivating a world wherein everyone has a fair and just opportunity to be as healthy as possible. 

As a 2019-2024 Albany Business Review’s Best Places to Work and a 2021-2026 Modern Healthcare’s Best Places to Work in Health Care award recipient, we strive to maintain a culture wherein high-performing, mission-driven team members collectively work toward better health for all. Dedicated to promoting a culture built upon autonomy, mastery, and purpose, we believe our differences in strengths and perspectives play an integral role in propelling us forward, while our core values ground us, serving as the common thread that unites our team. 

Why You Should Join Healthy Alliance 

We offer amenities, professional development opportunities, events, and programming that support the interests of our teams, while expanding and enriching our culture. Some of the benefits you can expect when you join Healthy Alliance include: 

• Competitive compensation package  
• Comprehensive insurance benefits available the 1st of the month after hire, including but not limited to medical, dental and vision, group short-term disability and life insurance with buy-up options, flexible spending and HSA company-contributed accounts, and more 
• 401K with a company match 
• Unlimited paid time off after 90 days of employment 
• Company-sponsored training and certification opportunities 
• Hybrid work environment and people-first workplace   
• A workplace that values safety, respect, employee engagement, recognition, and diversity 
• Salary range: $52,950-$60,892 per year, commensurate with experience 

Who You Are 

The Eligibility and Enrollment Specialist provides support to contracted partners, community members, providers, and managed care organizations (MCOs) throughout the eligibility process by answering questions and ensuring accurate information regarding eligibility and prior authorization requirements for timely service delivery. Through detailed understanding of program requirements and compassionate interaction with community members and their care team, this position will serve as a crucial link between health-related social need (HRSN) providers and the people they are designed to assist.  

What You’ll Do 

• Serve as the primary point of contact for internal teams, network providers, MCOs, Medicaid Members, and other external stakeholders for all enrollment, eligibility, and prior authorization activities and needs.
• Handle enrollment and eligibility phone calls and emails to answer questions, solve problems, and facilitate access to care for eligible Medicaid Members and their care teams.
• Validate Medicaid Member enrollment and eligibility through New York State Department of Health’s (NYSDOH) Medicaid Eligibility Verification System (MEVS) and/or Electronic Provider Assisted Claim Entry System (ePACES) to support screening, navigation, and enhanced HRSN services and assign Members to an established care team provider.
• Ensure accurate enrollment and eligibility records through proactive verification and reconciliation of enrollment and eligibility file data, including identifying and resolving discrepancies.
• Serve as the primary liaison between internal departments, including Operations and Finance, and MCOs to ensure eligibility discrepancies are updated.
• Manage changes to enrollment and eligibility, documenting and communicating updates to Social Care Navigators, enhanced HRSN service providers, MCOs, and other SCNs to support care access and transitions of care.
• Facilitate eligibility determinations for HRSN services based on established NYSDOH eligibility criteria. Manage SCN-required prior authorizations for designated enhanced HRSN services as per NYSDOH guidelines and SCN workflows.
• Proactively monitor enrollment and eligibility data to assign unassigned and/or disengaged community members for screening outreach.
• Maintain accurate and up-to-date documentation of enrollment, eligibility, and prior authorization information needed in advance of HRSN service provision.
• Support the Compliance team’s review and management of service authorizations, post-service/pre-payment reviews and appeal/service reconsiderations from Medicaid Members who have been denied assistance.
• Escalate any potential compliance risks as appropriate to Performance Management and/or VP of Compliance and Privacy.

How You’ll Contribute 

• Eligibility Interpretation: Accurately apply policy, navigate grey areas, and assess downstream impacts  
• Problem-Solving: Analyze complex cases, gather information, and determine next steps or escalations  
• Communication: Explain decisions clearly and professionally to members and partners  
• Adaptability: Adjust to changing systems, policies, and workflows 

This job description is not designed to cover or contain a comprehensive listing of task activities and/or duties that are required of the employee for this job. Responsibilities and activities may change at any time with or without notice.   

Requirements

What You’ll Need 

Education 

• High school diploma or equivalent.  
• Postsecondary education in Social Work, Human Services, Public Health, Healthcare Administration, or a related field preferred.  
• Equivalent combination of education and experience will be considered.  
• Coursework in communication, data management, and policy analysis is preferred.  

Experience:  

• Experience with Managed Care Organizations (MCOs) and/or case management preferred.  
• Familiarity with social services, public benefits, or healthcare programs preferred. 

Knowledge, Skills, and Abilities 

• In-depth knowledge of guidelines across federal, state, and local levels and ability to interpret and operationalize NYSDOH guidelines for management of HRSN services.
• Strong working knowledge of program eligibility criteria for successful enrollment of HRSN services.
• Demonstrated knowledge of policy changes and updates for accurate eligibility determination and program integrity maintenance.
• Ability to manage high-volume workload, review complex cases, and make decisions based on eligibility criteria   
• Familiarity with social services or benefits administration.
• Effective questioning and active listening to gather crucial applicant information to determine program eligibility.  
• Strong experience and demonstrated excellence in customer service.
• Ability to handle sensitive conversations with care, making applicants and care teams feel respected and understood.
• Strong critical thinking, decision making, and communication skills.
• Strong documentation skills.
• Ability to contribute individually to the success of key performance metrics. 
• Ability to successfully manage challenging conversations.
• Ability to multi-task and prioritize work, data entry, and attention to detail. Ability to effectively work in a hybrid environment that requires primarily remote work with some office-based time.
• Experience with MS Office Suite, including Word, Excel, PowerPoint, Outlook, and Zoom/Teams.
• Perform all work in accordance with Healthy Alliance core competencies and values.

Your next career opportunity is at Healthy Alliance! 

This position involves sedentary work that primarily involves sitting/standing, use of typical office equipment such as a computer, laptop, and cell phone. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Equal Opportunity Employer 

Healthy Alliance is an Equal Opportunity Employer and does not discriminate against any employee or applicant on the basis of age, ancestry, color, family or medical care leave, gender identity or expression, genetic information, marital status, medical condition, national origin, physical or mental disability, political affiliation, protected veteran status, race, religion, sex (including pregnancy), sexual orientation, or any other characteristic protected by applicable laws, regulations and ordinances. We adhere to these principles in all aspects of employment, including recruitment, hiring, training, compensation, promotion, benefits, social and recreational programs, and discipline. If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to [email protected].  

Privacy Requirement  

This job function involves potential access/interaction with protected health information. Position will be required to abide by company policies and procedures that support federal, state, and local HIPAA regulations. Any violations will be subject to company policy which includes disciplinary actions up to and including separation of employment.  

Healthy Alliance is an At-Will Employer.