Serves as a primary point of contact for individuals seeking assistance with various programs(Medicaid, SNAP, TANF, and other public assistance resources) provided by the MarylandDepartment of Human Services (DHS). Answers high volume inbound calls from Marylandresidents regarding DHS programs, policies, application processes and provides detailedinformation on state program eligibility, requirements, and application statuses. Assist callerswith completing applications and gathering necessary documentation. Addresses and resolvescustomer inquiries, complaints, and issues related to DHS services. Guides customers throughtroubleshooting steps for accessing DHS online portal, updating personal information, andunderstanding benefit decisions. Enters caller information and case details into the DHS E&Edatabase and maintains confidential records of customer interactions. Collaborates with otherDHS departments to transfer cases when specialized assistance is required. Provides referralsto other government or community resources

Perform member eligibility & enrollment activities, organizing data information and ensuring members are accurately enrolled into the member enrollment system timely. Research and resolve enrollment system discrepancies. Process membership terminations. Perform 834 file monthly reconciliation and membership audits. Insurance verification and coordination of benefits (COB). Validated COB data for state reporting and proper claim adjudication.

Managed the day-to-day operations of beneficiary eligibility & enrollment, disenrollment, reconciliation, retro processing activities and organizing data information. Managed the DTRR daily and monthly reconciliation, investigation and tracking of enrollment transactions.  Identified areas of opportunity, training and managed processes for quality improvements. Reviewed applications for accuracy (content and grammar), validating and entering data from beneficiary documents and other sources prior to submission. Researched and analyzed enrollment trends. Collaborated with various departments to identify and resolve complex issues, and applied Center for Medicare and Medicaid Services (CMS) applicable laws & regulations and applied best practices. Provided non-clinical eligibility support to medical management authorization operations. Completed effective and timely responses to member calls for eligibility inquiries. Directs the submission and monitoring of daily, weekly and monthly inventory reports. Attended CMS training sessions and other appropriate industry meetings. Established processes to monitor and provide eligibility enrollment files to vendors timely for ID cards and welcome packets. Managed team building, goals, objectives, development, staff performance expectations, competency assessments and performance evaluations. Responsible for effective and efficient time-card processing and attendance tracking.

Managed the Patient Registration Intake department planning and organizing the day-to-day operation. Managed the patient registration process from timely evaluation and admission of patients referred for service, insurance verification and documentation management, Electronic Medical Records. Monitored adherence to policies and procedures. Managed new and updated processes for quality and process improvements. Developed the department's quality audit process that addressed Key Performance Indicators (KPI’s). Ensured the appropriate notification of patient’s financial responsibility, benefits and payer authorization. Resolved complex issues, recommended, and implemented strategies to resolve problems. Provided staff performance expectations, competency assessments and performance evaluations. Responsible for effective and efficient time-card processing and attendance tracking in payroll system. Tracked and monitored the patient safety event and incident risk management portal. Worked collaboratively to review and develop a Continuous Quality Improvement (CQI) process.

Managed the day-to-day operations of the enrollment, eligibility, and revenue recovery department. Managed the enrollment of members enrolled in Medicaid and Alliance Health Plans. Ensured premium revenue accuracy via membership and capitation reconciliation. Researched, analyzed enrollment trends and prepared monthly membership reports. Monitored and maintained coordination of benefits to ensure proper adjudication of claims. Oversaw research of claim encounters for benefits and eligibility related errors. Oversaw the outreach resource recovery & retention process and reporting. Helped to implement the predictive dialer software call system. Reviewed member high cost claims to identify potential enrollment for other government programs. Served as enrollment liaison to the State Health Care Finance to resolve eligibility issues. Oversaw implementation of Trusted’s Affordable Care Act Certified Application Counselor program. Created training material and conducted staff training on the use of the CAC portal in DC Health Link. Performed departmental audits to evaluate the state 834/820 file data load transmissions. Coordinated with corporate IT to resolve file load programming and reporting issues. Performed vendor oversight ensuring contractual and regulatory/compliance requirements for ID cards and welcome packets.

Processed the Medicaid Enrollment and MAPD Reconciliation Departments deadline-driven Medicaid, Medicaid Waivers and Medicare-Medicaid (MMP) enrollment processes (Illinois and Texas Markets) Performed workload distribution and monitored production, timeliness, accuracy, and inventory Partnered with Maximus (enrollment broker) and the State ensuring enrollments and disenrollments were updated in internal systems accurately and timely Identified program deficiencies and collaborated with Information Systems to work towards resolution. Facilitated departmental communication regarding CMS correspondence and contract changes Created and maintained goals & objectives policies & procedures and job aids to stay compliant with all enrollment state and federal contracts and Service Level Agreements (SLA’s) Participated in the Hedis roadmap tracking and audit submission Ensured the Reconciliation departments reconciling of the Daily Transaction Reply Report from CMS. Conducted research in the Center for Medicare and Medicaid (CMS) guidance manual to ensure compliance with Federal mandated regulations as it related to membership enrollment Reviewed and analyzed beneficiary facts and evidence correspondence to ensure Best Available Evidence (BAE) policy requirements to determined Low Income Subsidy Implemented the Medicare Secondary Payer (MSP) & Coordination of Benefits (COB) process, including identifying areas related to best auditing practices, submitted Business Requirement Documents (BRD) and integration testing Processed the Prescription Drug Event (PDE) monthly reporting; ensuring member updates are reconciled to the Prescription Benefit Management System (PBM) Initiated the Bravo Retroactive Processing (RPC) submission, tracking, and disposition process. Established and maintained departmental Policies and Procedures

Managed a team comprised of 10-12 employees within the eligibility, enrollment and revenue recovery department. Effectively and timely managing the systematic enrollment and management of members enrolled both in the DC Alliance and Medicaid Health Plans while maintaining departmental compliance with the District guidelines. Ensuring that premium revenue is accurate via membership reconciliation, ineligible members are dis-enrolled timely and accurately to avoid improper claims payment and members are referred to the District for enrollment into an alternate program. Prepares monthly membership reports that include membership enrollment and disenrollment trends, and ensures that the reports are submitted to the appropriate department in a timely manner. Analyze and research members with a pregnancy diagnosis, high cost claims, and claims of members converted to fee –for- service (State) Medicaid and reconciliation of member roster to premium revenue. Serve as a liaison between the company and the Department of Healthcare Finance to resolves Medicaid eligibility issues. Serves as a liaison between the Information Systems, the director of member services and enrollment verification to ensure that membership’s information from the roster reports and capitation reports are received in a timely manner. Calculates PCP and NON PCP capitation reports and distributes to the executive management team. Reviews appeal & grievance issues related to enrollment and attend weekly meetings. Develops updates and maintains SOP’s operational policies and procedures related to the enrollment department. Updates daily membership counts and distributes to management and executive management team. Coordinate weekly outreach to moms with newborns to retrieve baby’s birth information for proper enrollment. Assist the Outreach Department with optimizing HEDIS performance measure results. Represent the department in cross functional trainings.