Enrollment Validation Specialist - Denver Health Medical Plan (Weekly On Site Requirement)

Job description

We are recruiting for a mission-driven Enrollment Validation Specialist - Denver Health Medical Plan (Weekly On Site Requirement) to join our team! We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. Our Values Respect | Belonging | Accountability | Transparency Department Managed Care Administration * Must Live in Colorado * This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Job Summary Under minimal supervision, contributes to the daily operations and analysis of enrollment related activities for all lines of business for the Denver Health Medical Plan. Compiles and analyzes reports for fallout and coordination of benefits, MedImpact, 834s. Reconciles complex sets of data received in order to validate reporting. Works and collaborates directly with the manager, and other partners such as all levels of management and employees, plan members, external consultants, DHAA, State and Federal entities and other community organizations to improve enrollment process and optimization of systems. Essential Functions : Collaborates with strategic initiatives and operations for the Health Plan Enrollment team. (10%) Works independently and with other Managed Care Departments to compile reports, attestations, and other submissions to submit to the State and CMS/HPMS (10%) Collaborates with other departments to compile, analyze and ensure the accuracy of data and documentation for internal and external compliance audits (10%) Development and adherence to enrollment processes, policies and procedures. (10%) Resolve claim concerns or member access issues related to enrollment and coordination of benefits. (5%) Reconciles complex sets of data received from CMS or the State in order to validate reporting, financial reconciliation, and encounter submissions to align with established goals and metrics (5%) Actively identifies problems and opportunities for improvement; identifies appropriate solutions and involves other in the implementation process (5%) Validate member enrollment and disenrollment. (5%) Partner with other departments to include Claims, Pharmacy, and IS in developing solutions as issues arise. (5%) Ensure compliance with all applicable Federal and State rules and regulations, validating contractual enrollment requirements are reflected in plan enrollment system. (5%) Analyze and reconcile data including claims, 834, and 820 files for trends and discrepancies, reporting any operational deficiencies to the Manager. (5%) Load electronic eligibility files and capitation files in 834 and 820 format. (5%) Monitor and assess electronic file uploads to ensure data quality. (5%) Analyze Special Enrollment documentation provided from members to determine Commercial coverage eligibility. (5%) Identify issues with enrollment, trend and perform root cause analysis for all lines of business. (5%) Utilize various data analysis tools such as Tableau, Excel and SQL to create reports for department and organizational use. (5%) Education : Bachelor's degree required - OR - 4 additiona l relevant years of experience in lieu of a degree required Work Experience : Four years of direct health care experience with a specific emphasis on Government Health Program operations, regulatory issues, policy development, or compliance required Licenses : Knowledge, Skills and Abilities : Extensive knowledge of managed care, Medicare, Medicaid and CHP+ eligibility and enrollment requirements, rules, and processes desired. Knowledge of Federal and Colorado State statutes, legislative initiatives and regulations, as well as Federal, State and local policies. Ability to develop data requirements and work with operations teams and groups to extract, organize and analyze data and trends. Ability to define problems: collect data, establish facts and draw valid conclusions to implement solutions. Skilled in analytical thinking, problem solving, and process improvement. Critical thinking, strong written and verbal communication skills, and the ability to effectively interact within a team. Microsoft Office Suite Tableau Proficiency in Health Plan Management Software involving Claims, Enrollment systems, and Government Data Portals. Knowledge of PC applications, specifically Microsoft Office products, and the ability to learn to computer applications. * Must Live in Colorado * This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Shift Days (United States of America) Work Type Regular Salary $67,300.00 - $101,000.00 / yr Benefits At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you. Here is a small list of our benefit programs: Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays 100% paid parental leave up to 6 weeks Immediate eligibility for retirement plans with employer contribution up to 9.5% Generous medical, dental, vision plans in addition to employer paid disability and life insurance. Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center Free RTD EcoPass (public transportation) Childcare discount programs & exclusive perks on large brands, travel, and more Tuition reimbursement & assistance Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways Professional clinical advancement program & shared governance Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer About Denver Health Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation. As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.