CommuniCare Health Services is currently recruiting for a Medicare Enrollment Compliance Specialist to join the leadership team of CommuniCare Advantage, our Medicare Advantage health plan.

Our corporate offices are located in the Blue Ash section of Cincinnati, OH, but we will consider both remote and on-site candidates with the right knowledge and experience.

PURPOSE/BELIEF STATEMENT

The Medicare Enrollment Compliance Specialist is responsible for the deployment of quality assurance strategies addressing all phases of the enrollment, billing, and reconciliation processing and monitoring accuracy standards for the Enrollment department. In collaboration with the Medicare Compliance Director and FDR Oversight Manager, the Medicare Enrollment Compliance Specialist will coordinate enrollment oversight activities of first tier, downstream, and related entities (FDRs) as necessary to meet the contractual oversight regulatory requirements for the prevention, detection, and correction of Fraud, Waste, and Abuse (FWA) and Medicare program non-compliance as established by the Centers for Medicare and Medicaid Services (CMS).

WHAT WE OFFER

As a CommuniCare employee you will enjoy competitive pay and PTO plans. We offer full time employees an outstanding, robust benefit package that includes life and disability plans and medical, dental and vision coverage, from quality benefit carriers. We also offer 401(k) with employer match and Flexible Spending Accounts. If you meet the requirements below, submit your resume for a chance to join the CommuniCare team!

QUALIFICATIONS/EXPERIENCE REQUIREMENTS

To qualify for the Medicare Enrollment Compliance Specialist position, you must have:

• Bachelor’s degree preferred and/or 3-5 years of relevant work experience required, preferably in a Medicare Advantage Plan.
• Previous enrollment, billing, and membership reconciliation experience in a healthcare/hospital setting is preferred.
• Critical thinking skills; clear and concise communication skills
• Advanced word processing, spreadsheet, and database skills are required.
• Medicare Advantage experience is preferred.

Knowledge/Skills/Abilities:

• Strong understanding of CMS Managed Care Manual chapters relating to member enrollments, marketing, and beneficiary protections including related guidance memos.
• Strong knowledge of industry standards and practices.
• Outstanding written and verbal communication abilities.
• Experience leading a team of 20 or more individuals.
• Familiarity with a variety of computer applications/software.
• Detail-oriented, well-organized, strong decision-making and problem-solving skills
• Ability to foster strong relationships.
• Ability to work within an integrated delivery system and a matrixed marketing organization

JOB DUTIES/RESPONSIBILITIES

As Medicare Enrollment Compliance Specialist, you will:

• Coordinate and implement ongoing quality improvement processes working with interdepartmental teams including:
  • Letters
  • Enrollment Processes
    • Including LIS & LEP processes
    • Loss of Special Needs process
    • RPC process
  • Billing Processes
  • Reconciliation Processes
  • OOA & Address Verification Processes
• Interpret and implement quality assurance metrics for performance improvement of all teams.
• Write or review quality assurance standards; study existing Policies, Procedures, and SOPs.
• Compile statistical data and write narrative reports summarizing quality assurance findings that allow management team to coach representatives appropriately.
• Perform appropriate CMS data submission quality checks and update developed tools as necessary.
• Coordinate the timely and accurate completion of CMS Part C and Part D Reporting Requirements and other required CMS submissions (e.g., Enrollment and Data Validation (EDV) Audit Packet Creation, monthly enrollment certification and attestation, etc.).
• Utilize the EDV to identify opportunities for improvement.
• Create and maintain training program for enrollment team.
• Support the accurate and complete reporting of compliance activities to the compliance committees and external oversight entities.
• Review and interpret all regulatory communications applicable to eligibility and enrollment for the health plan and FDRs to verify appropriate action, including dissemination to applicable areas and implementation of changes, is taken as needed.
• Coordinate and perform ongoing internal monitoring of activities including tracking compliance and implementing appropriate action as required.
• Perform eligibility and enrollment audits of operational areas and FDRs (desk or off-site) in accordance with annual work plan or ad-hoc audits to determine compliance with CMS rules and regulations including validation of data and internal controls.
• Other duties as assigned.

About Us

A family-owned company, we have grown to become one of the nation’s largest providers of post-acute care, which includes skilled nursing rehabilitation centers, long-term care centers, assisted living communities, independent rehabilitation centers, and long-term acute care hospitals (LTACH). Since 1984, we have provided superior, comprehensive management services for the development and management of adult living communities. We have a single job description at CommuniCare, "to reach out with our hearts and touch the hearts of others." Through this effort we create "Caring Communities" where staff, residents, clients and family members care for and about one another