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Job Summary:

Job Duties:

• Resolves and reconciles enrollment reports and all related eligibility issues by following policy and procedure as well as any state legislated coverage and eligibility guidelines.
• Initiates communication and literature to the newly enrolled Health Plan member, dependents and employer groups.
• Interprets and appropriately applies rules and regulations in contractual agreements and with employer groups and vendors.
• Performs membership data extract reports and supplies them to employer groups as an audit tool for accuracy and compliance with performance risk guarantee commitments.
• Updates, approves and interprets membership data and workflow produced by online software capabilities in employer group modules.
• Determines the eligibility of most members as well as processing terminations and disenrollments.
• Prepares, generates and appropriately disseminates letter communications to subscribers and members with regard to enrollment activity.
• Determines if services received are covered benefits as applicable by line of business and product design.
• Reviews suspended claims for resolution by applying current policies, procedures and benefits applicable to specific products.
• Provides team building resources to assist in directing peers to proper claims resolution policies and procedures in order to assist members and providers.
• Provides daily support and advice to member and provider services staff regarding claims issues.
• Researches claim issues from participating providers and identifies specific criteria for reconsideration for payment.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

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OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.

• KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
• EXCELLENCE: We treasure colleagues who humbly strive for excellence.
• LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
• INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
• SAFETY: We provide a safe environment for our patients and members and the Geisinger family. 

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.