[Hiring] TIHP Enrollment Senior Quality Specialist @Regency Integrated Health Services

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Enrollment, Fulfillment, & Billing Senior Quality Specialist is responsible for ensuring the health plan's continuous compliance with all CMS (Centers for Medicare & Medicaid Services) enrollment, disenrollment, fulfillment, and premium billing regulations by conducting critical audits, managing regulatory submissions, and validating internal controls.

• Conduct comprehensive member enrollment audits to ensure accuracy and compliance with CMS regulations, plan policies, and standard operating procedures.
• Verify the integrity of enrollment data, election periods, and eligibility criteria for Medicare Advantage and/or Part D members.
• Identify and report discrepancies or non-compliance issues found during audits to management and relevant teams for timely remediation.
• Perform Enrollment and Disenrollment Validation (EDV) audits as required by CMS.
• Conduct daily, monthly and routine audits.
• Review, process, and validate Medicare Advantage (MA) and Part D enrollment applications received via various channels (online, mail, phone) to ensure completeness and compliance with CMS regulations.
• Enter Service Request ticket for correcting LTC assignments, Facility Change Assignments and other tickets as needed.
• Track and reply to all email within the Enrollment Shared email box.
• Manage and resolve enrollment discrepancies, including Low-Income Subsidy (LIS) conflicts, entitlement issues, and late enrollment penalties (LEPs).
• Analyze and resolve complex member premium billing issues, including retroactive adjustments, payment discrepancies, and subsidy reconciliation.
• Process and document member premium refunds accurately and promptly, adhering to regulatory timelines and internal controls.
• Maintain detailed records of all billing adjustments and refunds for auditing and financial reporting purposes.
• Perform quality assurance (QA) reviews on mandated regulatory documents, forms, and communications (e.g., ANOC, EOC, LIS notices) to ensure 100% accuracy, proper formatting, and compliance with CMS requirements.
• Serve as a subject matter expert on CMS enrollment and billing mandatory letters, ensuring content accuracy for both the model language and the programming specification based on letter type and member level scenarios.
• Update letter matrix with all letters and programming specification year over year.
• Track and manage defects identified during testing, ensuring timely resolution before system deployments.
• Work independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations.
• Participate in any projects and/or daily tasks as assigned.

Qualifications

• High school diploma or general education degree (GED) required.
• Associates degree preferred.
• An equivalent combination of education, training, and experience.
• 5 years of healthcare experience required.
• Industry knowledge specific to the market served by the Health Plan - managed health care.
• Ability to demonstrate and act on an understanding of the collective concerns of internal and external customers.
• Demonstrates an understanding of how the parts of a problem are related and interact to create an outcome.
• Displays effective problem-solving skills, including the ability to resolve conflicts, troubleshoot issues and respond quickly to any situation.
• Must be customer focused, including displaying behaviors such as follow-through and courtesy.
• Ability to communicate effectively and be adaptable.
• Excellent oral and written communication skills.
• Able to read and interpret documents and calculate figures and amounts.
• Proficient in MS Office with basic computer and keyboarding skills.

Requirements

• Ability to work as a telecommuter.
• Ability to work some occasional evenings/weekends.

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