Analista De Elegibilidad & Afiliación Classicare
Regular
Non-Exempt
GENERAL DESCRIPTION:
Responsible for analyzing and assessing prospects’ eligibility for the Medicare Advantage Programs administered by the company. This assessment will be based on the eligibility rules and policies established by the Center for Medicare and Medicaid Services (CMS), Chapters 2 and 3 of the Managed Care Manual, the Puerto Rico Health Services Administration (ASES), the company, and any other regulatory agencies.
ESSENTIAL FUNCTIONS:
- Receives and processes applications for Enrollment, Disenrollment, Cancellation, and Coverage Changes within defined timeframes.
- Evaluate and analyze enrollment documents to ensure compliance with state, federal, and business regulations, determine prospect eligibility in CMS and ASES systems, enter or correct data in company application systems, and establish applicable eligibility periods.
- Identifying cases with missing information, initiating the returns process, and notifying the customer and the relevant departments.
- Validates reports of cases awaiting information to ensure timely processing in compliance with federal and departmental regulations.
- Ensures that all processed cases have appropriate notification letters within established periods.
- Monitors, analyzes, and documents cases under the Late Enrollment Penalty (LEP), Medicare Prescription Payment Plan (M3P), and Area Deprivation Index (ADI New Members) process in the corresponding systems.
- Provides information and recommendations for action on cases related to enrollment and disenrollment processes.
- Coordinates and approves the sending of Notification Letters resulting from the Primary Care Provider (PCP) transfer process.
- Analyze Capitation and Capitation Adjustment Report rejections referred to the financial department, making necessary adjustments in applicable systems, and reviewing and correcting cases to prevent errors in Capitation payments.
- Handles changes to PCPs in the relevant systems, according to company-approved assignment rules as referred by service areas, providers, or other departments.
- Reconciles the PCPs existing data in all the company systems and makes corrections if discrepancies are identified.
- Responds promptly to service requests from various departments via distribution lists or applications managed by the Unit.
- 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.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATION:
Education and experience: Bachelor’s Degree. At least six (6) months of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry.
OR
Education and experience: Associate’s Degree or Sixty to sixty-four (60-64) college credits. At least one (1) year of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry.
OR
Education and Experience: High School Diploma or Technical Course. At least two (2) years of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare 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 – Basic (comprehensive, writing, and verbal)
“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”
