Primary Responsibilities

The Enrollment, Fulfillment, & Billing Senior Quality Specialist is responsible for ensuring the health plan's continuous compliance with all CMS (Centers for Medicare & Medicaid Services) enrollment, disenrollment, fulfillment, and premium billing regulations by conducting critical audits, managing regulatory submissions, and validating internal controls.

Essential Functions

Enrollment Audits & Oversight:

 

Conduct comprehensive member enrollment audits to ensure accuracy and compliance with CMS regulations, plan policies, and standard operating procedures. Verify the integrity of enrollment data, election periods, and eligibility criteria for Medicare Advantage and/or Part D members. Identify and report discrepancies or non-compliance issues found during audits to management and relevant teams for timely remediation. Perform Enrollment and Disenrollment Validation (EDV) audits as required byCMS. Conduct daily, monthly and routine audits. Review, process, and validate Medicare Advantage (MA) and Part D enrollment applications received via various channels (online, mail, phone) to ensure completeness and compliance with CMS regulations. Enter Service Request ticket for correcting LTC assignments, Facility Change Assignments and other tickets as needed. Track and reply to all email within the Enrollment Shared email box. Manage and resolve enrollment discrepancies, including Low-Income Subsidy (LIS) conflicts, entitlement issues, and late enrollment penalties (LEPs).

 

Premium Billing & Refund Processing:

 

Analyze and resolve complex member premium billing issues, including retroactive adjustments, payment discrepancies, and subsidy reconciliation. Process and document member premium refunds accurately and promptly, adhering to regulatory timelines and internal controls. Maintain detailed records of all billing adjustments and refunds for auditing and financial reporting purposes.

 

Fulfillment Quality Assurance:

 

Perform quality assurance (QA) reviews on mandated regulatory documents, forms, and communications (e.g., ANOC, EOC, LIS notices) to ensure 100% accuracy, proper formatting, and compliance with CMS requirements. Serve as a subject matter expert on CMS enrollment and billing mandatory letters, ensuring content accuracy for both the model language and the programming specification based on letter type and member level scenarios. Update letter matrix with all letters and programming specification year over year. Track and manage defects identified during testing, ensuring timely resolution before system deployments. Works independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations. Participates in any projects and/or daily tasks as assigned.

Educational/Training Requirements

High school diploma or general education degree (GED) required. Associates degree preferred. An equivalent combination of education, training, and experience.

Experience and Skills Requirements

Required - 5 years of healthcare experience. Industry knowledge specific to the market served by the Health Plan - managed health care. Ability to demonstrate and act on an understanding of the collective concerns of internal and external customers. Demonstrates an understanding of how the parts of a problem are related and interact to create an outcome. Displays effective problem-solving skills, including the ability to resolve conflicts, troubleshoot issues and respond quickly to any situation. Must be customer focused, including displaying behaviors such as follow-through and courtesy. Ability to communicate effectively and be adaptable. Excellent oral and written communication skills Able to read and interpret documents and calculate figures and amounts. Proficient in MS Office with basic computer and keyboarding skills.

 

Availability/Travel Demands

Ability to work as a telecommuter Ability to work some occasional evenings/weekends