Manager - Eligibility

Description & Requirements

Maximus is looking for an Eligibility Manager to support our FED No Surprises Act (NSA) project.

This position is responsible for managing the overall eligibility review process for disputes in the Independent Dispute Resolution process between healthcare providers and insurance companies.

This position must be able to use a range of measurements to forecast, monitor, analyze, plan, and manage resources to achieve contractual service level agreements, while maintaining a high level of customer service.

The Eligibility Manager will be responsible for the daily operations of the eligibility review staff.

This role requires a deep understanding of the NSA, knowledge about healthcare service and items and strong critical thinking.

Essential Duties and Responsibilities:

- Stay updated on Enrollment and Eligibility performance standards, corporate, and project policies.

- Assist and inform staff about these policies and procedures.

- Provide guidance when handling escalated complaints and appeals.

- Identify and resolve employee issues, problems, and concerns.

- Address quality concerns with the Supervisory team regarding application and appeal reviews and corrections.

- Analyze weekly statistics, prepare daily and weekly reports.

- Monitor performance objectives for Enrollment and Eligibility Staff.

- Coach teams, set expectations, conduct performance evaluations, and support career development for assigned staff.

- Assess performance, provide appraisals, and implement corrective actions as needed.

- Evaluate training needs to ensure staff remains current with multiple programs.

- Keep leadership informed on quality, training, policies, procedures, staff issues, and departmental performance.

- Manage Eligibility Process: oversee the end-to-end eligibility review process, including intake, review, decision-making, and outreach with parties.

Monitor performance objectives for eligibility staff.

- Review disputes: analyze disputes to determine the eligibility of the dispute and make decisions based on policy guidelines and regulations.

Provide eligibility guidance for escalated disputes

- Compliance- ensure all eligibility decisions comply with relevant laws, regulations, and organizational policies.

Address quality concerns with the eligibility teams.

- Documentation- maintain accurate and detailed records of all disputes, decisions, and communications

- Stakeholder Communication- Act as the primary point of contact for parties, providing clear and concise information retarding the status and outcome of the eligibility review

- Team Leadership- manage and provide guidance to the eligibility teams, ensuring high standards of performance and professional development.

Coach teams, set expectations, conduct performance evaluations, and support career development for assigned staff.

Identify and resolve employee issues, problems, and concerns.

- Continuous Improvement- identify areas for process improvement a...