ELIGIBILITY AND ENROLLMENT SPECIALIST

Department: Operations Reports to (title): Escalation Center Manager

Hours/week: 40 Classification: Exempt

Type of Position: Full-time

PERFORMANCE EXPECTATIONS

In performance of their respective tasks and duties all employees of beWellnm are expected to conform to the following:

• Uphold all principles of confidentiality to the fullest extent.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and respectful manner with participants, employees, visitors and vendors.
• Comply with New Mexico Health Insurance Exchange’s policies and procedures.

POSITION PURPOSE

The Eligibility and Enrollment Specialist assists individual consumers with enrollment services for health insurance coverage through beWellnm, to include receiving inbound and outbound calls, identifying consumers’ needs, clarifying information, and researching and providing solutions under the direction of the
Escalation Center Manager. Through collaboration with staff at the NM Human Services Department, the position also provides information and assistance, as necessary, to individual consumers who may be eligible for Medicaid.

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES

1. Provides culturally-appropriate enrollment guidance to individuals on health insurance concepts and health care options.

2. Assists consumers in applying for health insurance coverage through beWellnm; refers consumers to agents, brokers, or other resources for assistance with health insurance needs.

3. Handles the escalation of individual situations requiring careful review of beWellnm and ACA policies and procedures.

4. Delivers the highest quality of customer service; builds and maintains a positive culture of service for consumers, exceeding consumers’ expectations.

5. Answers inbound calls in a timely manner, following Escalation Center scripts for all calls. Meet call center metrics in speed to answer and call abandonment rates.

6. Participates in outbound call projects as directed by supervisor.

7. Promotes beWellnm mission and goals.

8. Resolves issues and complaints from consumers, or appropriately directs consumers for assistance with resolution as required.

9. Escalate cases to supervisor that require input or guidance from beWellnm leadership, the Human Services Department, CMS, the Office of the Superintendent of Insurance, or other agencies.

10. Assists consumers in troubleshooting eligibility problems that cause an application to deny, suspend or otherwise not complete.

11. Develops, maintains, and submits reports in a timely manner; proactively communicates with Escalation Center Manager and other beWellnm staff to keep them informed of activities, status of projects, issues, and risks.

12. Receive inbound SHOP calls, handles initial, tier 1 questions and escalates more complex SHOP calls to SHOP operations specialist.

13. Performs other duties and completes special projects, as assigned.

MINIMUM MANDATORY QUALIFICATIONS

Experience: 2 years’ experience in customer service

Education: High School Diploma or GED equivalent

Mandatory: Some knowledge of the Affordable Care Act (ACA), the New Mexico Health Knowledge, Skills, Insurance Exchange Act (NMHIXA) and/or some experience in Medicaid

Abilities and Other eligibility preferred Qualifications:

• Ability to successfully pass background check by Office of Superintendent of Insurance
• Ability to complete and maintain all necessary training to become a certified Enrollment Counselor by the Office of Superintendent of Insurance

• Ability to complete and maintain all necessary training to become a PE/MOSAA Determiner by the State of New Mexico Human Services Department, Income Support Division.

• Spanish/English fluency is ideal
• Excellent customer service skills
• Ability to successfully complete required training on beWellnm systems.
• Ability to multi-task, set priorities, and manage time effectively
• Superior written and verbal communications skills and the ability to handle sensitive and confidential situations
• Proven ability to provide guidance and documentation
• Strong interpersonal and relationship-building skills with a proven ability to build and maintain positive, effective relations
• Strong phone and verbal communication skills, as well as active listening skills
• Effective problem-solver with the ability to develop and advance alternative solutions
• Able to work in a team-oriented environment and effectively communicate both verbally and in writing
• Ability to effectively report on the status and implementation of projects to senior management
• Knowledge of Microsoft Office Suite; Microsoft Word; Microsoft PowerPoint; Microsoft Excel and internet software

• A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers

PREFERRED QUALIFICATIONS

• High School Diploma or GED equivalent
• Experience in health insurance industry
• Call Center experience, including experience with customer relations management (CRM) software

WORK ENVIRONMENT

Office environment:
The work environment characteristics described here are representative to those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk, hear and perform repetitive motions. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors and staff. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Mental demands:

There are a number of deadlines associated with this position. The employee must be able to handle frequent interruptions and must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

OTHER

Confidentiality: All employees must uphold all principles of confidentiality to the fullest extent. This position has access to sensitive information and a breach of these principles will be grounds for
Immediate termination.

Background This position may be subject to a criminal history background check, a suitability background
Investigation: check and/or a Fair Credit Reporting Act (FCRA) check. Candidates must be able to successfully pass all required background checks to qualify for this position.

Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed. In order to provide equal employment and advancement opportunities to all individuals, employment decisions at the New Mexico Health Insurance Exchange will be based on merit, qualifications, and abilities. The NM Health Insurance Exchange does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability or any other characteristic protected by law.

Job Type: Full-time

Pay: $50,112.00 - $62,640.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Ability to commute/relocate:

• Albuquerque, NM 87109: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Customer service: 1 year (Preferred)

Work Location: One location

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