SUMMARY
Manages eligibility and enrollment activities pertaining to the Active Employers and Medicare Programs in compliance with the Plans and Trusts, the Center for Medicare and Medicaid Services (CMS), and other entities, regulations and statutes. Directs key processes assuring Eligibility Department and Organization-wide compliance with Plan Documents, and with Federal and State laws. Assures secure use and storage of sensitive beneficiary data, in compliance with Plan Documents, and with Federal and State laws.
PRIMARY DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Directs the Medicare and Black Lung eligibility systems and coordinates enrollment activities, which includes identifying beneficiaries who are eligible for Medicare and/or Black Lung benefits, coordinating timely enrollments to ensure maximum reimbursements from these programs. Prepares Black Lung cost reports, monitors and analyzes payment, eligibility, and enrollment/disenrollment reports from Government agencies and resolves issues related to such reports, and coordinates the exchange of eligibility information with the Funds’ claims processing vendors and with Government entities.
Works with representatives from a large Employer Plan group whose health benefits are administered by the Funds, coordinating enrollments, terminations, changes to benefits, ensuring that data changes and corrections are made timely, and responding to eligibility inquiries. The beneficiary population from this Employer Plan group includes active employees, with more dependents and more frequent life events (new hires, layoffs, and recalls), so timely processing is essential.
Manages the process of assuring continued Medicare, Black Lung, and other program eligibility by all enrolled beneficiaries. Produces appropriate surveys and uses other mechanisms to assure compliance with Continued Eligibility rules. Directs staff and monitors systems components of related processes.
Monitors, evaluates, and advises Funds’ staff regarding changes in coverage or administrative requirements pertaining to the Medicare, Black Lung, Workers Compensation Programs, and to other health related legislative developments. Advises Funds staff regarding services covered by the Medicare and Black Lung Programs to ensure benefits are processed and allocated in compliance with program requirements.
Responds both in writing and verbally to Federal Government agencies and officials, Medicare Part B carriers and Part A intermediaries, employers, beneficiaries, insurance companies, UMWA officials, and Funds staff regarding resolution of eligibility and enrollment issues, questions concerning CMS and HCPP coverage and requirements, legislative updates, plan interpretation issue, etc. Serves as the Funds’ primary representative in relationships with several Government agencies.
Prepares, reviews and analyzes various monthly and ad hoc reports for program monitoring and evaluation purposes. Develops and conducts training and staff development sessions for Funds staff regarding complex eligibility issues as needed. Assists in the development, revision, and implementation of eligibility criteria and maintenance of eligibility records and procedure documents, and monitors compliance with new procedures.
Monitors and assures Department compliance with HIPAA and other privacy, safety and risk-control regulations. Monitors the safety of department information and resources.
Coordinates all activities involving audits of the department. Serves as a liaison to internal and external audit agencies.
Negotiates Funds’ role as carrier for DOL health benefits. Substantiates and communicates to US Government officials the efficacy and accuracy of Funds’ benefit delivery methods in role as carrier. Develops and delivers persuasive communications with high level officials. Develops alliances and creates rapport with officials at various levels to assure avenues of communication remain open.
Serves as the Department’s expert resource on Coordination of Benefits (COB) issues.
Accesses individually identifiable health information and is responsible for adhering to all Funds policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information.
SUPERVISORY RESPONSIBILITIES
Directly supervises one or more classified employees in accordance with the Funds’ policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems; motivating staff and assuring appropriate productivity and quality levels.
INDUSTRY KNOWLEDGE:
In-depth knowledge of the administration of benefit plans and Federal Government Programs, such as CMS and CMS Managed Care Systems, and Federal Black Lung ; in-depth knowledge of ERISA, HIPAA, and COBRA; and general knowledge of the insurance and coal industries. Understanding of relevant Government Agencies’ structures and roles.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
Bachelor’s degree (B. A.) from four-year college/university, or four to six years related experience and/or training of which two to four years should be analytical, managerial or supervisory, or equivalent combination of education and experience. Broad exposure to various business environments.
LANGUAGE SKILLS
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from Funds’ staff, government agencies, employers, insurance companies, and beneficiaries.
Ability to communicate effectively and persuasively. Ability to effectively build alliances.
MATHEMATICAL SKILLS
Requires use of intermediate mathematical formulas and calculations to prepare or interpret, usage, statistical or financial information.
REASONING ABILITY
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
CERTIFICATES, LICENSES, REGISTRATIONS
None required for this position.
OTHER SKILLS AND ABILITIES
Requires the ability to represent the Department to the Trustees, Government Officials, and others inside and outside the Funds. Requires professionalism and the ability to interact with others respectfully.
Requires computer skills at an intermediate level. For example, generating word processing letters/reports, use of database software, basic spreadsheet usage and/or operating printers. Ability to interpret computer reports generated by Federal Government agencies, and to create reports to ensure contractual compliance.
PHYSICAL DEMANDS
The physical demands described here are representative of those that are typically experienced by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to sit and use hands to finger, handle, or feel objects, tools, or controls. The employee is occasionally required to walk and reach with hands and arms. Specific vision abilities required by this job include distance vision, color vision, and the ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually quiet. Requires frequent day trips to Government Agencies, and occasional meetings in subterranean Government offices. Occasional travel by car. Infrequent long-distance travel.
COMPLETE BACKGROUND CHECK REQUIRED.