Analista De Afilicacion Y Elegibilidad Comercial

Analista de Afilicacion y Elegibilidad Comercial

GENERAL DESCRIPTION:

Analyzed and processed eligibility transactions and received them in the Commercial Eligibility unit. Validates member be eligibility and updates information in MHS, as applicable.

ESSENTIAL FUNCTIONS:

• Evaluates and determine the eligibility rules that apply to the Cost Plus, ASO & Full Insurance groups, perform data entry in the Power MHS eligibility system, and create, or update the Life Insurance screens the insured's record, as applicable.

• Analyzes the insured's requested coverage, family composition ("Tiers"), benefits package, and divisions (COBRA, LTD, Retired, etc.) to which the insured belongs to validate and ensure that the information is complete and error free.

• Processes eligibility maintenance in the system such as cancellations, activations, changes, etc., to ensure data integrity

• Performs audits and analysis of eligibility discrepancies requested by the Cost Plus, ASO & Full Insurance groups to validate the data reflected in MHS and ensure that it contains the correct information

• Analyzes the reporting of coverage, billing, and policyholder setup errors referred by the Billing unit and corrects them in the system so that cases can be billed correctly.

• Analyzes VIP policyholder eligibility history to determine the conditions under which the policyholder's setup should be reflected in MHS

• Attends to and answers account eligibility questions and handles cancellations, activations, changes, and errors in coverage referred by external customers

• Prepares letters of denials, cancellations, and/or requests for information and submits them to the unit Clerk to be sent to customers upon request

• Communicates with customers to request additional information to complete the eligibility transaction

• Validates and resolves eligibility situations referred by the Call Center and Claims department to allow payment of the claim and/or access to benefits through MHS

• Updates the production sheet daily to report cases worked and provide the status of pending cases to be worked
and maintain the confidentiality of information and documents handled.

• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices

MINIMUM QUALIFICATIONS

Education and Experience: 60 university credits equivalent to two (2) years of studies or an associate degree. At least six (6) months to one (1) year of experience in processes related to group and individual enrollment and data entry experience, preferably in the Health Insurance Industry.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: N/A

Other: N/A

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"