This position reports to the Supervisor I Enrollment and Eligibility. The Eligibility Specialist III will be responsible for performing the most complex work and specialized assignments, both automated and manual, in determining eligibility for employee benefit plans within the Western Growers Assurance Trust (WGAT) and Pinnacle Claims Management, Inc. (PCMI) accounts on the company’s processing system. This includes working on exceptions, researching escalated requests as well as performing all the activities that the Eligibility Specialists I and II perform. This role involves providing escalated direction and training to less experienced staff, managing complex cases, and ensuring compliance with regulations and policies.

·      BA/BS degree in accounting, finance, or business-related field preferred, and five (5) to seven (7) years of Accounting/Business experience with knowledge of generally accepted accounting procedures, analytical abilities, or equivalent combination of education and experience.

·      Three (3) years’ experience as an Eligibility Specialist I & II or equivalent background is preferred.

·      Advanced skills in establishing priorities, multi-tasking, time management, and the ability to work independently with minimal supervision in a team environment.

·      Expert knowledge of generally accepted Health Care Eligibility and Billing procedures as well as Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California-COBRA, Multiple Employer Welfare Arrangement (MEWA) and Employee Retirement Income Security Act (ERISA) legislation.

·      Advanced experience with Microsoft Office Suite: Word, Excel, Visio, PowerPoint, and Outlook.

·      Excellent experience providing customer service to a variety of client contacts via email and telephone.

·      Strong ability to research and resolve technical and client issues as they arise with minimal direction.

·      Excellent written and oral communication skills including modern business communications, formatting of professional letters, reports, and phone etiquette.

·      Advanced knowledge of health insurance operations and industry.

·      Bilingual in Spanish, both verbal and written a plus.

·      Ability to work overtime as needed.

·      Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.

·      Home router with wired Ethernet (wireless connections and hotspots are not permitted).

·      A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)

·      A functioning smoke detector, fire extinguisher, and first aid kit on site.

·      Maintain Eligibility and Billing for WGAT and PCMI accounts as assigned including clients that submit eligibility electronically.

·      Review manual and/or (adds, changes, terminations) in company’s processing system as received from the client or internal sources in accordance with Participation Agreements, Employer Policy Statement, Eligibility Guidelines, and/or Summary Plan Descriptions.

·      Knowledge of audit procedures to be able to assist audit team when needed.

·      Produce electronic spreadsheets and/or reports for daily reporting purposes.

·      Perform full reconciliations on accounts in order to confirm that the group is in compliance.

·      Research and correct cash application issues in company’s processing system. Determine and correct out-of-balance ledger items on accounts. Contact clients to explain and resolve billing and payment discrepancies. Verify or authorize refunds for terminations and/or overpayments.

·      Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.

·      Maintain performance in accordance with established quality standards, as measured by audit metrics. Consistently meet or exceed audit score requirements to ensure accuracy, compliance, and service excellence.

·      Create and document Standard Operating Procedures (SOP’s). Identify communication gaps in SOP so they may follow along during   training.

·      Identify, initiate, and implement process improvements and/or innovation.

·      Maintain a business relationship with the group contact, handle escalations that arise with the group, process the group's EDI (electronic data interchange) files, handle all manual adjustments and billing issues for the special handle account, and any other issues that may arise.

·     Provide timely and effective Customer Service to clients for requests, inquiries, or issues concerning enrollment and/or billing items on their account via phone calls by logging into Genesys and taking calls based on daily phone schedule.

·      Provide timely and effective Customer Service to clients for requests, inquiries, or issues concerning enrollment and/or billing items on their account via phone calls by logging into Genesys and being available to take calls based on daily phone schedule.

·      Interface effectively with internal departments and external vendors, brokers, or other business contacts to coordinate interrelated activities and resolve eligibility and/or billing issues as they arise.

·      Meet processing cycle time standards and production due dates as set forth by management.

·      Serve as a representative of Western Growers and PCMI displaying professionalism, knowledge, customer service, and discretion in all interactions with other members of the WGAT/PCMI community and their customers.

·      Train Administration team in daily production methods.

·      Identify and resolve training deficiencies on an as-needed basis.

·      Motivate employee performances by providing recognition for a job well done or constructive feedback when needed.

·      Provide one-on-one coaching for internal and external customers.

·      As the subject matter expert, support and maintain effective working relationships with a variety of stakeholders and serve as the point of contact for the teams.

 

·        Maintain integrity and transparency in all tasks, ensuring alignment with team and organizational goals.

·        Hold oneself accountable by taking ownership of actions, decisions, and their outcomes.

·        Reflect on personal performance regularly, identifying areas for improvement and celebrating successes.

·        Commit to continuous learning and growth, seeking feedback and implementing constructive changes.

·       Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.

·       Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.

·       Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.

·       Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).

·       All other duties as assigned.