UPMC Health Plan is hiring Enrollment Specialist I positions for the Commercial Enrollment department.  These are full time positions working Monday through Friday daylight hours with a 9AM – 5PM shift and overtime as needed.  This will be a hybrid position consisting of working from home and in office.

The Enrollment Specialist will be responsible for the creation and maintenance of eligibility in the transactional system, responding to both internal and external customer inquiries, and resolving issues to meet or exceed service requirements. To successfully perform the role, an Enrollment Specialist must have a comprehensive understanding of enrollment regulations and complete all duties with strict regard to policies and procedures. Completes all duties with strict regard to policies and procedures set forth by Enrollment Services Manager, Centers for Medicare and Medicaid Services (CMS), Pennsylvania Department of Welfare (DPW), and Pennsylvania Insurance Department (PID). Performs duties related to the processing and maintenance of all member requested transactions, include generation of required letters to ensure enrollment and/or disenrollment processes are completed compliantly. Interacts with both internal and external customers to address and resolve inquiries or complaints.

Responsibilities:

Understanding of varied and detailed enrollment and disenrollment requirements and processing rules based upon the product (HMO, PPO, EPO, SNP, PDP, Select, Supplemental, or National Complimentary) and Individual vs. Employer Group, including, but not limited to, understanding and application of service areas by product. Maintain employee/insured confidentiality. Ability to analyze information to make appropriate decisions regarding enrollment/disenrollment, complying with applicable regulations and governance. Interact with Sales staff to ensure all required date elements for completed application are received and any issues are addressed timely, in accordance with compliance requirements. Ability to make eligibility determinations based on CMS (Part A/Part B Eligibility), DPW (Medical Assistance Eligibility), and/or PID requirements, in accordance with the application election period guidelines. Ability to accurately identify appropriate election period based upon analysis of beneficiary/member history and regulatory guidance. Comprehension and application of eligibility regulations to process enrollment transactions and generation of corresponding letters to members. Must keep up to date with new regulations and guidance. Process all types of enrollment and disenrollment transactions in accordance with company policies and procedures in a timely manner while meeting production and quality goals. Initiation and generate of appropriate correspondence based on type of transaction processed, includes initiation of outreach requests and written correspondence (letters), as necessary. Daily clerical responsibilities related to processing and electronic storage of member correspondence. Identify areas of concern or trends that may compromise client satisfaction or compliance with government regulations. Support team projects within Enrollment Services; other projects as assigned.