Eligibility Service Specialist II
San Diego, CA

Job Description

Eligibility Service Specialist II

If you're interested in a career within a customer-focused, team-oriented environment that rewards innovation, quality, integrity and collaboration, MedImpact Healthcare Systems, Inc. welcomes your application. MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Position Summary

The Eligibility Service Specialist (ESS) supports proactive Eligibility Management Services (EMS) related to inbound and outbound batch file handling and ad-hoc data requests in support of Major Medical Carriers and eligibility Third Party Administrators (TPAs). The ESA provides day-to-day operational support to the Business Solutions and Client Technical Solutions teams and works hand in hand with Business Systems Specialists to execute on task-based eligibility and accumulator services. All levels of this position are expected to work directly with major medical carriers and TPA stakeholders to own and drive issue resolution and will require strong business acumen and client communication skills.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Eligibility Service Specialist I

* Performs proactive eligibility and accumulator management services for Self-Insured (SI) client base, especially with regard to major medical carriers (e.g. Anthem, Cigna, Aetna, etc.) and TPAs interfacing with MedImpact to own and drive issue resolution with external partners
* Provides primary day-to-day operational production support for major medical carriers and larger client eligibility TPAs, becoming the centralized eligibility Subject Matter Expert (SME) for these strategic partners
* Proactively reviews eligibility and accumulator log files providing a high degree of issue resolution resulting in improvement in eligibility quality and timeliness performance guarantees for SI client base
* Performs research and simple cleanup activities related to eligibility and accumulator synchronization issues with appropriate parties (e.g. clients, TPAs, Medical Carriers, client team BSAs)
* Implements eligibility issue tracking processes to increase client satisfaction and operational efficiency
* Contributes to technical system enhancements for error log handling, failed member and accumulator record re-processing on behalf of clients, and automated file monitoring and alerts in collaboration with IT Data Exchange
* Facilitates TPA and medical carrier batch file processes, creating, assigning and monitoring SalesForce tasks for IT Support for recurring and one-time requests
* Verifies TPA and medical carrier batch file processing requests are completed, validating file delivery status or manually posting file(s) to secure FTP directories
* Navigates UNIX environments to locate, assess and move data files to support various eligibility and accumulator data processes
* Runs predefined SQL queries to support eligibility and accumulator ad-hoc reporting requests
* Actively supports Implementation efforts, providing direct assistance to Operations Business Solutions and Client Technical Solutions BSA team to:
* Coordinate with Data Exchange to perform standard TPA and medical carrier file conversions (834 and accumulator) for eligibility and accumulators for SI clients
* Manually load TPA group, member and accumulator files into production for large TPAs and medical carriers

Eligibility Service Specialist II

* Includes all Level I functions and assists with special projects and assignments as delegated
* Performs research and more complicated cleanup activities related to eligibility and accumulator synchronization issues with appropriate parties (e.g. clients, TPAs, Medical Carriers, client team BSAs) including but not limited to re-accumulation service tasks
* Applies SQL expertise to create and modify predefined SQL queries to support eligibility and accumulator ad-hoc reporting requests
* Writes and maintains detailed reference documentation in support for eligibility and accumulator data services
* Drives service task enhancements for eligibility technical systems from creation to implementation

Education and/or Experience

Level I: Associate's degree and 1 year of related experience required in Pharmacy Benefit Management (PBM), Pharmacy, Managed Healthcare or similar role; or an equivalent combination of education and experience. At least one year of data analysis related experience as applicable to the role.

Level II: Bachelor's degree from four-year college or university and at least two (2) years of related experience required in Pharmacy Benefit Management (PBM), Pharmacy, Managed Healthcare or similar role; or an equivalent combination of education and experience. At least two years of, configuration or data analysis related experience as applicable to the role. Basic project management skills are also desired.

Computer Skills

* To perform this job successfully, an individual should have intermediate to advance knowledge of Microsoft Office Suite and hands on experience using SQL, PL/SQL or any other equivalent versions
* Experience creating SQL queries in support of troubleshooting, design and prioritization strongly preferred for Level II
* Experience using business applications such as MedAccess, MedOptimize, SalesForce required following training
* The qualified candidate must also have UNIX experience and understanding of best practices, design principles, and data standards

Other Skills and Abilities

Data analysis experience preferred and healthcare eligibility experience a plus.

This position is eligible for Employee Referral Bonus at Level I

EOE, M/F/D/V

OSHA/ADA:

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.