Enrollment Reconciliation Specialist - 09-001-s&f-ma
Public Consulting Group (Boston, Massachusetts)

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Company Overview:

Public Consulting Group (PCG) was founded in 1986 as a privately held consulting firm serving state and local health and human services programs.  Today, with more than 500 professionals in 24 offices around the U.S. and in Montreal, Quebec, we offer a wide range of management consulting and technology solutions to help public sector clients achieve their performance goals and better serve populations in need.  PCG continuously updates its knowledge of industry best practices and maximizes partnerships and investments to deliver the leading consulting approaches and technologies to the marketplace.  The firm is committed to providing proven solutions and outstanding customer service to clients in each of our three practice areas:

 Education
Offering full-service consulting integrated with innovative and scalable technology solutions to address the changing needs of the K-12 community.

 Health, Human Services, and Other Government
Helping state and local governments achieve their performance goals, with seasoned professionals and proven solutions to increase program revenue, cut costs, and improve compliance with state and federal regulations.

 Consumer-Directed Services
Helping state, county, and local public agencies deliver a service model to persons with disabilities that allows these consumers to choose what services they receive, how they're delivered, by whom, within their budgets.

Job Description:

The Enrollment Reconciliation Specialist establishes, documents, and conducts procedures related to the reconciliation of Medicare and Medicaid enrollment membership in senior HMO plans.  He/she submits enrollment data and reviews regularly received reports from the Center for Medicare and Medicaid Services (CMS), Massachusetts Medicaid (MassHealth), and their contractors to identify and resolve data discrepancies. This involves working closely with other members of the PCG team and the client’s internal staff, as well as coordinating with representatives of CMS, MassHealth and their contractors. The Enrollment Reconciliation Specialist must have a good understanding of Medicare and Medicaid enrollment and reconciliation procedures, as well as project management skills related to general HMO operations.

Responsibilities:

I.         Enrollment Data Processing (25%)

     1.        Generate enrollment data files, QA the files with the Plan’s Member Services staff, and submit them to CMS and its contractors.

       2.           Review enrollment data reports from CMS, MassHealth, and their contractors to:

            A.         Confirm enrollment actions

            B.          Identify members who require notification, and informing the Plan’s Member Services staff to send the notification

            C.          Identify and respond to information requests from CMS

            D.         Identify potential enrollment and data discrepancies

II.          File Transfer from Medicare, Medicaid and Other Data Sources (10%)

      1.           Download all files from CMS and its vendors

      2.           Perform quality assurance to confirm all data has been received by CCA

III.        Enrollment and Data Discrepancy Resolution (30%)

       1.           Research enrollment data discrepancies to identify correct version of information. This always involves reviewing information from a variety of internal and external data systems; it often involves working with the Plan’s internal staff; and it sometimes involves coordinating with representatives of CMS, MassHealth and/or their contractors

      2.           Resolve discrepancies by:

           A.         Correcting Plan data directly or by working with the Plan’s staff; or

           B.          Working with Plan staff to gather appeal information, and submitting this information to CMS and/or MassHealth via their contractors, the CMS Regional Office, and/or the CMS Division of Payment Operations (DPO)

      3.           Research PDE (Prescription Drug Event) errors to identify and correct information that caused the errors. This usually involves working with the Plan’s internal staff and staff of the Plan’s Pharmacy Benefit Manager

IV.        P2P (Plan-to-Plan) Reconciliation (20%)

      1.           Identify and track cases requiring P2P payments to/from other plans:

          A.         Calculate amounts payable to outside plans and work with the Plan’s staff to have checks cut and mailed to outside plans

          B.          Calculate amounts receivable and send payment requests to outside plans

          C.          Monitor receivable and payable amounts outstanding and work with other plans to resolve amounts outstanding

       2.           Identify and track cases requiring TrOOP (True-Out-Of-Pocket Cost) information to be sent or requested:

          A.         For members leaving the Plan for another plan, request TrOOP information from the Plan’s PBM (Pharmacy Benefit Manager), and send it to outside plans

          B.          For members joining the Plan from another plan, request TrOOP information from the other plans, and send it to the Plan’s PBM

V.          Process Development and Documentation (15%)

       1.           Participate in process design sessions with PCG team

       2.           Document process work flows

       3.           Develop production and management reports detailing process status

          4.           Preview CMS and MassHealth memos to identify regulatory, procedural and/or technical changes which are likely to have an impact on the PCG team’s work

       5.           Provide ongoing monitoring of automated processes to identify gaps in process

          6.           Work with IT consultants to automate portions of established reconciliation procedures

Essential Qualities and Skills:

· Bachelors Degree preferred.

· Minimum of two years of administrative support experience required, preferably in a Medicare and/or healthcare environment dealing enrollment/membership related processes.  Other relevant experience includes medical billing and claims processing.

· Demonstrated competence to work independently: to prioritize and manage multiple activity streams, and to meet deadlines with attention to detail and quality.

· High degree of professionalism with a strong customer service focus.

· Demonstrated ability to coordinate work with team members, client staff, and third parties.

· Demonstrated math, analytical, and problem solving skills.

· Strong verbal and written communication skills.

· Proficiency in Microsoft Word and Excel, database skills a plus.

PCG is a fast paced, energetic environment with dedicated professionals who are passionate and committed to the core values of the organization. Successful candidates must be willing to operate in both a team situation and autonomously with minimal supervision. They must possess strong skills in the areas of interpersonal communication, analysis, critical thinking, attention to detail, multi-tasking, and oral and written communication.

For more information on Public Consulting Group, please visit our website at www.pcgus.com

PCG is an equal opportunity employer.

Contact Information:

Corporate Recruiter

Public Consulting Group

148 State Street, Floor 10

Boston, MA  02109

pcghr@pcgus.com