Eligibility and Enrollment Specialist

Life at Healthy Alliance

At Healthy Alliance our purpose is to improve health and empower the underserved. Every community has its own needs affecting the health of those who live learn work and play within them. Our network brings together organizations big and small to coordinate and collaborate so that all communities have reliable access to the resources they need. Why Because every New Yorker deserves the same opportunity to be healthy.

Designated as the Social Care Network (SCN) Lead Entity for the Capital Region Central NY and North Country under New Yorks 1115 Waiver Amendments SCN & Health-Related Social Needs (HRSN) Program we are responsible for ensuring that there is a seamless consistent end-to-end process for HRSN screening navigation and the delivery of HRSN and other services to thousands of Medicaid Members. Transformative in nature this novel Program will further sustain our mission of advancing health equity within and across historically marginalized communities.

As a 2019-2024 Albany Business Reviews Best Places to Work and a 2021-2025 Modern Healthcares Best Places to Work in Health Care award recipient we strive to maintain a culture wherein high-performing mission-driven team members collectively work toward better health for all. Dedicated to promoting a culture built upon autonomy mastery and purpose we believe our differences in strengths and perspectives play an integral role in propelling us forward while our core values ground us serving as the common thread that unites our team.

Why You Should Join Healthy Alliance

We offer amenities professional development opportunities events and programming that support the interests of our teams while expanding and enriching our culture. Some of the benefits you can expect when you join Healthy Alliance include:

• Competitive compensation package
• Comprehensive insurance benefits available the 1st of the month after hire including but not limited to medical dental and vision group short-term disability and life insurance with buy-up options flexible spending and HSA company-contributed accounts and more
• 401K with a company match
• Unlimited paid time off after 90 days of employment
• Company-sponsored training and certification opportunities
• Hybrid work environment and people-first workplace
• A workplace that values safety respect employee engagement recognition and diversity
• Salary range: $52950-$60892 per year commensurate with experience

Who You Are

The Eligibility and Enrollment Specialist provides support to contracted partners community members providers and managed care organizations (MCOs) throughout the eligibility process by answering questions and ensuring accurate information regarding eligibility and prior authorization requirements for timely service delivery. Through detailed understanding of program requirements and compassionate interaction with community members and their care team this position will serve as a crucial link between health-related social need (HRSN) providers and the people they are designed to assist.

What Youll Do

• Serve as the primary point of contact for internal teams network providers MCOs Medicaid Members and other external stakeholders for all enrollment eligibility and prior authorization activities and needs.
• Handle enrollment and eligibility phone calls and emails to answer questions solve problems and facilitate access to care for eligible Medicaid Members and their care teams.
• Validate Medicaid Member enrollment and eligibility through New York State Department of Healths (NYSDOH) Medicaid Eligibility Verification System (MEVS) and/or Electronic Provider Assisted Claim Entry System (ePACES) to support screening navigation and enhanced HRSN services and assign Members to an established care team provider.
• Ensure accurate enrollment and eligibility records through proactive verification and reconciliation of enrollment and eligibility file data including identifying and resolving discrepancies.
• Serve as the primary liaison between internal departments including Operations and Finance and MCOs to ensure eligibility discrepancies are updated.
• Manage changes to enrollment and eligibility documenting and communicating updates to Social Care Navigators enhanced HRSN service providers MCOs and other SCNs to support care access and transitions of care.
• Facilitate eligibility determinations for HRSN services based on established NYSDOH eligibility criteria. Manage SCN-required prior authorizations for designated enhanced HRSN services as per NYSDOH guidelines and SCN workflows.
• Proactively monitor enrollment and eligibility data to assign unassigned and/or disengaged community members for screening outreach.
• Maintain accurate and up-to-date documentation of enrollment eligibility and prior authorization information needed in advance of HRSN service provision.
• Support the Compliance teams review and management of service authorizations post-service/pre-payment reviews and appeal/service reconsiderations from Medicaid Members who have been denied assistance.
• Escalate any potential compliance risks as appropriate to Performance Management and/or VP of Compliance and Privacy.

This job description is not designed to cover or contain a comprehensive listing of task activities and/or duties that are required of the employee for this job. Responsibilities and activities may change at any time with or without notice.

What Youll Need

Education

• Relevant education and experience in areas of study including social or clinical work health or social care program administration.
• Coursework in communication data management and policy analysis is preferred.

Professional Work Experience

• Managed Care and Case Management experience preferred.
• Experience dissecting legal and procedural documents to ensure assessments are accurate and in line with current policies.
• Experience working with community members and care teams to determine eligibility and collaborating with care teams to obtain prior authorization for programs and services.
• Experience applying federal state and local regulations to evaluate applications for HRSN services.

Knowledge Skills and Abilities

• In-depth knowledge of guidelines across federal state and local levels and ability to interpret and operationalize NYSDOH guidelines for management of HRSN services.
• Strong working knowledge of program eligibility criteria for successful enrollment of HRSN services.
• Demonstrated knowledge of policy changes and updates for accurate eligibility determination and program integrity maintenance.
• Ability to manage high-volume workload review complex cases and make decisions based on eligibility criteria
• Familiarity with social services or benefits administration.
• Effective questioning and active listening to gather crucial applicant information to determine program eligibility.
• Strong experience and demonstrated excellence in customer service.
• Ability to handle sensitive conversations with care making applicants and care teams feel respected and understood.
• Strong critical thinking decision making and communication skills.
• Strong documentation skills.
• Ability to contribute individually to the success of key performance metrics.
• Ability to successfully manage challenging conversations.
• Ability to multi-task and prioritize work data entry and attention to detail. Ability to effectively work in a hybrid environment that requires primarily remote work with some office-based time.
• Experience with MS Office Suite including Word Excel PowerPoint Outlook and Zoom/Teams.
• Perform all work in accordance with Healthy Alliance core competencies and values.

Your next career opportunity is at Healthy Alliance!

This position involves sedentary work that primarily involves sitting/standing use of typical office equipment such as a computer laptop and cell phone. The physical demands described here are representative of those that must be met 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.

Equal Opportunity Employer

Healthy Alliance is an Equal Opportunity Employer and does not discriminate against any employee or applicant on the basis of age ancestry color family or medical care leave gender identity or expression genetic information marital status medical condition national origin physical or mental disability political affiliation protected veteran status race religion sex (including pregnancy) sexual orientation or any other characteristic protected by applicable laws regulations and ordinances. We adhere to these principles in all aspects of employment including recruitment hiring training compensation promotion benefits social and recreational programs and discipline. If you require reasonable accommodation in completing this application interviewing completing any pre-employment testing or otherwise participating in the employee selection process please direct your inquiries to

Privacy Requirement

This job function involves potential access/interaction with protected health information. Position will be required to abide by company policies and procedures that support federal state and local HIPAA regulations. Any violations will be subject to company policy which includes disciplinary actions up to and including separation of employment.

Healthy Alliance is an At-Will Employer.