Eligibility Reconciliation Analyst

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under the Manager, Business Systems Operations Support, the Eligibility Reconciliation Analyst will identify, research & resolve discrepancies between source data and IEHP eligibility data. The incumbent is responsible for identifying and resolving discrepancies in Member’s demographic, enrollment, premium and eligibility data between federal and/or state data against IEHP’s membership.  The Reconciliation Analyst will perform a variety of duties related to membership reconciliation from various sources.

The Eligibility Reconciliation Analyst is independent and acts as a subject matter expert for Covered California eligibility.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Telecommute schedule.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Collaborate with internal and external stakeholders, researching and resolving eligibility discrepancies per regulatory guidelines.
2. Oversight and ownership of the CCA mandated monthly reconciliation and dispute process, ensuring the calendar provided by CCA is followed and files are delivered on-time.
3. Perform data comparison between regulatory files and IEHP’s membership data.
4. Review rejected Pharmacy claims to ensure Eligibility in the PBM system to accurate and coordinate with the Pharmacy team to reprocess.
5. Verify the files to ensure proper formatting and layout while confirming the accuracy of all data fields and their contents.
6. Provide technical guidance and knowledge to internal and contracted IT departments, including the ability to effectively speak to Covered CA's Data Integrity Unit.
7. Research and review enrollment or eligibility transaction errors and make the necessary changes to resolve the error type provided.
8. Identify and review Premium/Financial 834 discrepancies (Premium amounts, APTC, CSR, etc.) and work with the Finance Operations team as necessary. Coordinate and collaborate discrepancy results with the Finance Operations department to ensure full transparency regarding CCA dispute disposition.
9. Conduct analysis on weekly reconciliation results to ensure trends are identified timely and discrepancies trend down. Review and conduct root cause analysis on discrepancies identified by Covered California via the Monthly Reconciliation process.
10. Ensure compliance with technical requirements and write business requirements for internal and contracted IT departments. Make sure that internal and external responses are provided by specified regulatory deadlines established by Covered California. Communicate risks and compliance concerns to leadership, providing actionable recommendations for improvement.
11. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Education & Requirements 

• At least two (2) years of relevant experience: a minimum of one (1) year of experience demonstrating excellent organizational, time management, and facilitation skills required
• Experience demonstrating initiative and self-direction with the ability to work well independently and in teams while serving as a Subject Matter Expert (SME) required
• Also includes at least one year of eligibility research experience in a managed care setting required
• Minimum of 1 year experience and knowledge of Covered California regulatory requirements and membership reconciliation preferred
• Minimum of 1 year experience and knowledge of Medicare regulatory requirements preferred
• Experience with Covered CA or other Exchange products preferred
• Bachelor’s Degree in Business Administration, Health Care Administration, Computer Information Systems (CIS), Management Information Systems (MIS), or other related field from an accredited institution required
  • One (1) of the following scenarios will be accepted in lieu of a Bachelor’s degree:
    • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position: Two (2) years of Health Care or Managed Care Operations experience and a minimum of two (2) years of data reconciliation or experience working with Eligibility data is required
    • This experience is in addition to the minimum years listed in the Experience Requirements above

Key Qualifications

• Experience and/or knowledge of the 834-file format system preferred
• Requires excellent critical thinking, root cause analysis, and problem-solving skills as well as excellent written and verbal communication skills with the ability to communicate and present effectively in large forums to discuss complex information
• Also requires a high level of attention to detail
• Ability to work independently and solve complex problems with little to no assistance
• Effectively manage multiple competing priorities and adhere to strict timelines
• Ability to effectively manage multiple competing priorities
• Ability to manage multiple projects of varying complexity, priority levels and deadlines

Start your journey towards a thriving future with IEHP and apply TODAY!

Telecommute (All IEHP positions approved for telecommute may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)