Enrollment Reconciliation Specialist AlohaCare is a local, non-profit health plan serving Hawai`i's low-income residents with free Medicaid and dual Medicare health insurance coverage. Our members include children, seniors and adults residing on all islands. We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care. Our approach is to meet the whole-person health and social needs of members. Through our community partnerships we offer innovative services such as connection to social service agencies, Native Hawaiian healing services and in-home primary care for qualified members. Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all. We are Hawaii's third-largest health plan and offer a wide network of quality primary care, specialists, hospitals, pharmacies and among many other providers across the state. AlohaCare employees have a passion for helping Hawai`i's most underserved communities. Our caring culture is fundamental to our company-wide team approach to providing high quality services. We support our employees with a supportive and positive work environment, healthy work-life balance, continuous communication, and a generous benefits package. AlohaCare's leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication. AlohaCare's comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program. The Enrollment Reconciliation Specialist provides advanced operational oversight of Medicare D-SNP enrollment reconciliation and CMS/MARx transactions. This role is responsible for identifying, researching, and resolving complex enrollment discrepancies that may impact member eligibility, claims, pharmacy, accumulations, and regulatory reporting. The position serves as a subject matter resource to Enrollment and Plan Operations, coordinating with internal departments, CMS and other stakeholders to ensure enrollment data is accurate, timely, and fully reconciled across systems.
Primary Duties and Responsibilities:
Identify and investigate discrepancies between CMS/MARx internal enrollment systems, and downstream systems.
Research root causes of enrollment discrepancies and develop appropriate corrective actions.
Manage and track member reinstatements, retroactive enrollment changes, and CMS transaction corrections through resolution.
Reconcile Medicare D-SNP enrollment with applicable Medicaid/QUEST eligibility and identify issues affecting member eligibility.
Validate enrollment changes and their downstream impact on claims, pharmacy, member benefits, accumulations and other operational systems.
Maintain detailed reconciliation tracker, issue logs, audit documentation, and management reporting.
Identity trends and recurring issues and perform root cause analysis and process improvement.
Provide guidance and subject matter expertise to enrollment staff on complex reconciliation issues and CMS transactions.
Develop and maintain reporting that provides leadership with visibility into enrollment status, outstanding discrepancies, transaction activity, risk, and resolution progress.
Escalate significant enrollment issues and potential members or financial impacts to leadership.
All other duties assigned.
Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
Responsible for maintaining AlohaCare's confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
Requirements:- High school diploma or equivalent.
- Minimum of 3 years of healthcare enrollment, Medicare Advantage, D-SNP, membership, reconciliation, or health plan operations experience.
- Strong knowledge of CMS/MARx enrollment processes.
- Experience working with Medicare Advantage and preferably D-SNP/Medicaid populations.
- Advanced Excel and data-reconciliation skills
- Demonstrated ability to independently research complex enrollment issues and determine appropriate resolution.
- Achieves results, builds trust, communicate effectively, customer and quality focused.
- Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
- Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
- Professional telephonic etiquette skills .Ability to solve problems, analyze, think critically and make good judgment.
- Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
- Able to work independently with minimal supervision.
- Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
- Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
- Data entry experience with a high degree of accuracy and attention to detail.
- Intermediate skills in Microsoft Programs: Word, Excel or Access Databases, Outlook and PowerPoint .Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.
- Available to work a flexible schedule, including weekends and holidays, when necessary.
Preferred Requirements:- Experience with CMS 834 transaction and MARx and RPC processing
- Experience with retroactive enrollment, disenrollment, and reinstatement processing.
- Experience with Medicaid/QUEST or integrated Medicare/Medicaid programs.
- Experience supporting CMS audits and regulatory requirements.
- Experience developing reconciliation processes, controls and reporting.
- Mental, Physical and Environmental Demands:
Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
In office working environment.
May require prolonged sitting- up to 4 hours.
Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.
Salary Range: $17.00 - $22.00 an hour
AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.
