会员运营高级助理 - 回溯性

Job Description
A bit about this role:
The Senior Associate, on the Membership Operations team, is a key player within a pivotal function. Devoted Health's Membership Operations team is entrusted with the R&D and operational execution behind the integrity of our members' data — the data that everything else in health plan operations depends on. The team includes SNP eligibility validation, Enrollment, Member Data Integrity, Member Financial Integrity, Member and Payment Reconciliation, Quality Management, and Strategy.
Retroactivity cuts across all of them. When a member's enrollment record is wrong — wrong plan, wrong county, wrong effective date, wrong subsidy status, or missing entirely — the correction is retroactive, and it touches enrollment, payment, claims, pharmacy, and premium billing simultaneously.
Your Responsibilities and Impact will include:

• Researching escalated and complex retroactive transaction work: You will address problems by drawing on CMS guidance, established procedures, and professional judgment, while leveraging resources across the organization to gain input.

• Assist in building the tooling that makes change repeatable: Playbooks, intake, readiness trackers, adoption dashboards. Anything we repeat should run as durable, self-serve tooling, not a manual doc.

• Prepare and submit transactions through the appropriate channel — internal processing via MARx and the MAPD Help Desk for current and prior month effective dates, and RPC submission via eRPT for older effective dates.

• Monitor case aging against category boundaries and prioritize work by the risk of a case aging out of a favorable category rather than by simple queue order

• Track and report on category mix, detection latency, aging, and slippage; escalate capacity constraints before they translate into aged cases

• Coordinate downstream remediation so members are made whole: claims re-adjudication, pharmacy support, premium adjustments and refunds, subsidy and penalty corrections, prescription drug event corrections, materials and ID card reissuance, and member and provider notification

• Serve as a knowledgeable point of contact for escalated member situations involving retroactive corrections

• Maintain established confidence in applicable federal and state laws, regulations, CMS policy guidance, and contract standards; conduct business-specific analysis and communicate business impacts, requirements, and recommended actions

• Monitor and analyze non-compliant trends and root causes, and collaborate with stakeholders — Enrollment, Sales Compliance, Agent oversight, Product, and Engineering — to correct upstream gaps so the retroactive correction is not needed next time

• Maintain a complete, reconstructable record of retroactive cases sufficient to support audit, data validation, and annual readiness

• Relate openly and comfortably with a diverse group of people as a representative of the Membership Operations team

Required skills and experience:

• Ability to work in a startup, fast-paced environment

• 3-5 years of experience in healthcare, or experience with Medicare or Medicaid requirements

• Working proficiency with data tools — spreadsheets at minimum, SQL or similar query experience a strong plus

• Experience writing business requirements or partnering with technical teams on operational tooling a plus

• Self-motivated, with the desire and flexibility to collaborate with co-workers in a virtual environment as a team player

• Entrepreneurial, proactive, and flexible, comfortable in a high-growth environment, with an ability to proactively work across an organization

• Compassion for the healthcare challenges facing the Medicare population

• Ability to continue to learn and stay current on Medicare initiatives in the marketplace

Desired skills and experience:

• Direct experience with retroactive enrollment and payment corrections strongly preferred, including RPC submissions and MARx transaction processing

• Familiarity with CMS reply and membership reporting, complaint tracking, and grievance processes

Salary:$70,000 - $85, 000 annually
The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.
Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.
Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
Originally posted on Himalayas