Eligibility Representative

DaVita Medical Group - El Segundo, CA3.3

Responsible for the accurate maintenance of computerized insurance information in the legacy system. Duties include research, analysis and reconciliation of complex eligibility issues. This position is required to effectively communicate with all the departments within HealthCare Partners (HCP), employer groups, health plans, contracted vendors and members to establish members’ insurance coverage.

Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Researches, analyzes and reconciles the discrepancies between health plan eligibility tape files and the legacy system according to established department guidelines. Verifies that all enrollments contain the correct group numbers, plan and effective date as reported by the health plan.
Obtains and input into the legacy system accurate fee-for-service eligibility and benefits information for non-HMO members including PPO, EPO, Medicare and POS product lines.
Accurately inputs into the computer system manually all HMO members that are not added by electronic tape process.
Manually reconciles eligible HMO members in the legacy system for health plans that are not processed by electronic tape.
Researches and resolves discrepancies in the PCP assignment between the health plan eligibility tape files and the legacy system. Makes sure of accurate capitation payments to providers.
Reviews all waivers signed in the previous month and processes accounts according to waiver guidelines.
Interacts with members through the telephone to resolve eligibility issues.
Receives and researches telephone inquiries pertaining to eligibility issues for all HCP sites, central departments (i.e., Utilization Review, Patient Services, Care Management, Business Office, Claims), outside vendors, physicians, etc.
Researches insurance coverage on new unverified members prior to their scheduled appointments and communicates the outcome to the site per established department guidelines.
Follows through to resolution with health plan on unresolved eligibility issues. Refers to Supervisor when additional intervention is necessary.
Adheres to the guidelines established by the Eligibility and Care Management departments in assessing the appropriateness of member requests to transfer to HCP.
Researches claims that cannot be processed due to eligibility issues and maintains 24-48 hour turnaround time to ensure claims payment compliance.
Accurately links employer group to benefit plan in the IDX system according to Eligibility department guidelines.
Assists Supervisor/Lead in training new and existing staff members.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.

High school diploma, G.E.D. or equivalent. Includes special certification required for specific jobs.

Over 1 year and up to and including 3 years of experience.
1 to 2 years working with HMO insurance verification.

Computer literate.
Proficient in all Microsoft applications.
Keyboard skills equivalent to typing 40 wpm.
Excellent customer service skills.
Ability to follow verbal and written instructions.
Strong verbal and written communication skills. Good command of the English language, grammar and spelling.
What's the first thing that happens when one of the leading independent medical groups in the country comes together with a global leader in health care? Opportunity. With DaVita Medical Group, HealthCare Partners, The Everett Clinic, Northwest Physicians Network, MountainView Medical Group and Magan Medical Clinic joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. We're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(SM)

Careers with OptumCare. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. OptumCare, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)

Diversity creates a healthier atmosphere: OptumCare and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. OptumCare and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.