The Operations Eligibility Specialist assists with maintenance of eligibility files in varying formats processed through automated and/or manual eligibility data/files. This role utilizes and understands eligibility processes to make updates to various systems, providing manual eligibility support for all clients. This role Identifies and recommends modifications and enhancements that will increase efficiency in the process and use of systems. This role will frequently communicate with internal and external partners regarding day-to-day aspects of eligibility files including issues and concerns. This position provides support during the implementation of client eligibility including, but not limited to file changes, process improvements, automation, or resolution of ongoing issues. This role also represents eligibility operations in internal/external meetings.
This position is responsible for providing accurate, efficient and timely contract support and service for the assigned client. Operational management of assigned book of business in order to achieve profitable retention of accounts. Responsible for timely and accurate entry and maintenance of operational records and information in multiple databases. Researches and resolves questions and complaints, and ensures that information in all databases is accurate and properly configured to support operations.
Performs daily operation-specific duties that directly relate to the products and/or services assigned
Supports in the development and maintenance of a strategic business plan that fully reflects the clients program objectives and how the company provides solutions to align to those objectives and specifically guides our operational, financial, clinical and relationship initiatives. Understands the client's organizational structure and demonstrates the ability to apply this knowledge in business and retention planning for the client.
Ensures Service Level Agreement performance. Documents and maintains required reporting
Owns overall internal account satisfaction within the company as well as satisfaction with each support area particularly account management.
Develops and maintains multi-level relationships within client organizations which includes maintaining contract requirements. Communicates and updates account service information to appropriate internal staff. Makes presentations to the professional community to enhance the visibility and image of the company.
Supports the account management team to ensure performance standards are measurable and realistic to achieve and/or exceed to avoid penalties. Manages methodology, reporting and communications.
Ensures all Customer and Account-Facing services are provided in a consistent and timely fashion.
Resolves or appropriately escalates customer service issues in conjunction with operations (claims, service, and systems).
Coordinates with the compliance department on knowing and understanding state and federal regulations and the implication to customer impact.
Proactively communicates to internal and external contacts.
Demonstrates contract understanding and detailed knowledge of business requirements.
Assists in the coordination with legal to ensure contract compliance.
Supports the account management team in the definition of customer reports and ensures coordination with the client.
Prepares and supports presentations of customer reports with meaningful analytics, trending and recommendations for program improvement based on findings.
Supports the account management team ensuring revenue goals are met, administrative expenses are managed and segment profit targets are achieved for assigned account(s).
Supports up-sell and renewal activities across assigned account.
Effectively explains or uses technology (internally and externally) for customers.
Understands about the company business and operational decisions to predict impacts on customer.
Demonstrates knowledge of the company products and how multiple products are interdependent within the customer contract deliverables and clinical outcomes.
Identifies products and services that bring solutions to the customer based on a thorough understanding of the customer strategic business goals and the business needs.
Other duties as assigned.
Other Job Requirements
Responsibilities
Bachelor's degree required.
Two years of experience in account management required.
May consider an additional 4 years of directly relevant experience in customer service, account management or project management in lieu of degree.
Ability to prioritize workload effectively within a fast-paced, time sensitive and results oriented environment.
Demonstrated willingness to be flexible and adaptable to changing priorities.
Detail oriented.
Effective verbal and written communication skills.
Proven ability to work effectively both independently and in a team based environment.
Strong multi-tasking and organizational skills.
Strong presentation skills.
Strong working knowledge of Microsoft Office Product Suite.
Willing and able to quickly learn new software applications as needed.
General Job Information
Title
Operations Eligibility Specialist I
Grade
22
Work Experience - Required
Account Management
Work Experience - Preferred
PBM (Pharmacy Benefit Management)
Education - Required
A Combination of Education and Work Experience May Be Considered., Bachelors
Education - Preferred
License and Certifications - Required
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
