Eligibility Specialists System Manager In USA

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Petaluma,  CA Remote  Full Time

Eligibility Specialist
Location: Petaluma, CA
Employment Status: Full-Time, Hybrid

Position Summary:

The Eligibility Specialist is responsible for health plan membership and physician data maintenance to support all analytical needs with respect to eligibility, membership, and capitation. The primary role is to resolve eligibility issues and update member records in the database to ensure accuracy of the data. The incumbent will assist in processing a large volume of monthly files received from Health Plans and audit for any discrepancies. This incumbent will also assist in the production of less complex analyses and routine and ad hoc reporting. Eligibility Specialists

Salary Range: $21.83- $25.87 DOE

Essential Job Functions:

  • Convert health plan raw data file to readable formats.
  • Validates the extraction, transformation, and loading of data into the test database for completeness and integrity.
  • Upon test authentication, upload monthly membership data by health plan/provider/member including enrollment, terminations, member migration, and other metrics in production. Eligibility Specialists
  • Identifies and resolves any membership issues, movements, patterns, and trends, and makes appropriate updates to members records in production.
  • Responsible to work all eligibility open tickets.
  • Run EMPID files as needed.
  • Identifies and reports the more complex cases for further follow up by Director. Eligibility Specialists
  • Conduct routine quality audits of eligibility uploads to ensure data integrity is clean, accurate and consistent and reports findings to Director.
  • Provides back-up to other resources and functions within the team.
  • Responsible to participate in system upgrade testing pertaining to eligibility.
  • Performs other than normally assigned duties, as directed, and required, within and outside of the department to support Meritage’s overall business needs, goals, and objectives. Eligibility Specialists
  • Models professional work standards and behaviors to maintain and strengthen a professional working atmosphere and strictest confidentiality within the department and with other Meritage internal and external customers and work partners. Eligibility Specialists
  • Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others. Eligibility Specialists
  • Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.

Job Requirements

Requirements & Qualifications:

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  • A High School Diploma.
  • A minimum of 1 year of work experience related to healthcare/managed care eligibility, enrollment/membership. Eligibility Specialists
  • Experience utilizing and performing eligibility/enrollment functions with a managed care system. (eg. Medvision QuickCap 7 – preferred, EZ-Cap, Epic-Tapestry). Eligibility Specialists
  • Type of knowledge expected in the healthcare managed care industry including, but not limited to, eligibility, policies, procedures, processes, terminology, and methodologies. Eligibility Specialists
  • Proficient in Microsoft Office Suite (Word, Excel, Outlook, Teams, PowerPoint). Eligibility Specialists
  • Effective written and verbal communication skills required. Excellent interpersonal skills, including the ability to communicate clearly and professionally, both verbally and in writing. Eligibility Specialists
  • Must have solid critical thinking and problem-solving skills and be results driven.
  • Must have excellent task management skills, which include ability to organize and prioritize duties, attention to detail, and time management. Eligibility Specialists
  • Must possess a customer service orientation with a commitment to excellence and quality.
  • Must demonstrate the values of integrity, accountability, and respect in dealings with others and with his/her work product. Eligibility Specialists


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