Senior Eligibility Processor

Job Description

The Senior Eligibility Processor is responsible for the activities related to the process of uploading Health plan eligibility files to Prospect’s core system (IDX), for the purpose of managing eligibility information. This role requires someone to function with a high degree of independence, dependability, and data entry accuracy. The position is responsible for the daily operational activities which will ensure successful and accurate inbound and outbound transmissions.

Responsibilities

The Senior Eligibility Processor is responsible for the activities related to the process of uploading Health plan eligibility files to Prospect’s core system (IDX), for the purpose of managing eligibility information. This role requires someone to function with a high degree of independence, dependability, and data entry accuracy. The position is responsible for the daily operational activities which will ensure successful and accurate inbound and outbound transmissions.

Meet with health plan and vendor(s) on issues with health plan file data. Articulate eligibility issues and processes with health plan/vendor contacts and management. Perform testing and troubleshooting on new or updated health plan files. Establish processes for new health plan files.

Administer all aspects of health plan eligibility file loads into eligibility management software and IDX, including eligibility file setup, data integrity analysis, field mapping, and implementation of network affiliation and plan codes. Maintain accuracy in working within eligibility management software and IDX. Perform Monthly Reconciliations to ensure variances from the health plan files to IDX are <=1% variance or <= 50-member difference. Work directly with health plans and vendor contacts on issues involving health plan files and data integrity.

Generate audit reports and guide Eligibility Team on working audit reports work queues for assigned health plan. Research identified issues and escalate errors to the appropriate departments. Ensure that operational duties will meet or exceed all relevant stated Service Level Agreements (SLA). Train new hires as a subject-matter expert on Eligibility processes.

Actively participate in supporting special projects as requested. Complete variety of projects of an analytical nature as assigned by management or identified through own work.

Qualifications

Minimum Education: High School Diploma/BA, or equivalent work experience.

Minimum Experience: Experience operating PC-based software programs. 4+ years working within Enrollment/Eligibility for a health plan, IPA, Medical Group, or Provider Office. Experience using SQL and Access databases and other software applications within Enrollment/Eligibility. Experience working within IDX a plus. Experience pulling files via health plan websites, SFTP, and e-mail.

Req. Certification/Licensure: NONE

"Location-Based Pay Adjustment"

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.