Job Description

Job Title: Eligibility and Retention Specialist

Department: Member Services / Care Coordination

Reports To: Operations Manager

Date: 04/28/2024

Position Overview:

The Eligibility and Retention Specialist plays a key role in supporting member engagement, retention, and eligibility verification. This role is ideal for professionals with a general knowledge of managed care and strong communication, organizational, and systems skills. The specialist will coordinate outreach efforts, ensure proper documentation and compliance, and serve as an advocate for members navigating services and benefits.

Scope of Responsibilities:

• Verify and maintain member program eligibility according to internal and external guidelines, including:
• Compiling necessary documents for eligibility verification
• Entering and updating data within required systems
• Tracking and reporting eligibility changes to appropriate teams
• Conduct outreach to new members via phone, SMS, or other platforms to support orientation and engagement
• Assign new members to appropriate facilities and ensure accurate Head of Household (HOH) designations for minors
• Review cases for disenrollment eligibility based on established criteria
• Facilitate access to benefits and support services for an assigned caseload
• Serve as an advocate for members during coordination with other service providers
• Maintain accurate and up-to-date records, reports, and administrative documentation
• Retain documentation in compliance with organizational and regulatory standards
• Participate in internal meetings, trainings, and committees as assigned
• Collaborate with other departments to address issues related to member retention, quality assurance, utilization, customer service, and provider relations
• Assist in audit preparation and compliance reviews, including:
• Merging and organizing documents using Adobe Acrobat
• Reviewing files to ensure policy and regulatory adherence
• Supporting audit processes by submitting required records
• Support special projects, including quality improvement, health education, provider relations, and outreach activities

Qualifications:

• High school diploma or GED required
• Minimum 2 years of relevant full-time experience
• Proficiency in Microsoft Office and general computer literacy
• Bilingual (Spanish/English) preferred; additional languages a plus

Competencies:

• Integrity and trust
• Customer service orientation
• Technical and functional proficiency
• Strong communication, interpersonal, and organizational skills

Pride Health offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors

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