Under the supervision of the THPMP Premium Billing Manager, this individual must be able to independently reconcile the member payments received from outside sources (i.e., CMS, SSA, State Government) for premium payment/subsidy. Timely reporting of discrepancies and resolution of issues is required. This position is also responsible for review and approval of all adjustment processed. He/she must actively participate in project initiatives sharing subject matter expertise to achieve business goals. Ensure compliance with all CMS & State regulations and internal department processes while fully supporting the expansion of production offerings and process changes as a result of such.
He/she must be able to proactively escalate issues, identify areas of process improvement, and to demonstrate positive and strong collaboration both within the Premium Billing Team, and across all THPMP departments.
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)
* Using Premium Billing principles, independently research adjustments submitted for review. Validate that the adjustment submitted is necessary and accurate.
* Review backup for submitted with the adjustment.
* Timely response back with either approval or denial including comments as to why an adjustment was denied.
* Utilize MP to ensure approved adjustments were entered into the system accurately.
Reconciliation of Premium Payments/Subsidies
* LEP/LIS Monthly Reconciliation
o Post the LEP file monthly and identify any issues with the posting process, document, review with our Business Analyst and work to resolution. Notify Customer Relations, Finance and other impacted departments.
o Review member specific LIS data issues, check MARx for proper rider needed in MP/Diamond, coordinate with Membership Accounting to insure all rider updates are processed prior to next invoice run.
* SSA Premium Withhold Outreach/Updates
o Responsible for all outreach projects to members on SSA Premium Withhold. By utilizing MP, identify members with outstanding balances associated with SSA premium withhold. Research the data in CMS system to validate payment status. Establish the schedule for the outreach. Generate, quality check and send letter and statement of account to the impacted members. Monitor the progress of the outreach and report to Supervisor/Manager on a monthly basis (minimum).
o Complete a monthly review of membership premium withhold status per MP compared to CMS. For any member discrepancies, work with CMS contact and Enrollment to bring to resolution.
* Based on Member reporting from CMS, for any transaction code impacting SSA premium withhold, generate the corresponding letter for the member, insure MP is updated with change and notes and have letter scanned in to Macess for documentation.
* Participate in small to medium projects and workgroups
* Cross-train team members as an added level of production support
* Quality check own work and that of others within their department
Meet productivity standards for quality and quantity
* Learn and apply regulatory changes to daily production tasks (i.e. Late Enrollment Penalty, Low Income Subsidy, Employer Group Downgrade)
* Actively participate in Corporate Compliance and CMS training (i.e. CBTs, instructor-lead training) within established timeframes
* Review and/or revise department policy & procedures based on subject matter expertise
* Ensure internal procedures and CMS/State requirements are met Ongoing