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Eligibility & Retention Specialist

Job Ref: 58180
Category: Professional
Location: 160 Water St. #3, New York, NY 10038
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $51,500.00
Salary Range: $51,500.00 - $55,000.00

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

Under the direction of the Quality and Compliance Director , the Eligibility and Retention Specialist has a general knowledge of managed care, with skills in information systems. The Eligibility and Retention Specialist is responsible for coordinating provider and member outreach activities in support of ongoing member engagement in care and maintenance of program eligibility.

Job Description

  • Ensures member program eligibility in accordance with established internal and external requirements.
  • Compiles necessary documentation for new member eligibility verification and enters data necessary for documentation within set guidelines.  
  • Monitors and tracks changes in member eligibility and informs appropriate departments within set timeframes.
  • Conducts outreach by phone/SMS or other methods for new member orientation and Medicaid renewal/recertification reminders
  • Assists in facilitating access to benefits and support services to a designated group of members.  Acts as a member advocate in specific situations and/or discussions with other care providers.  
  • Maintains required records, reports and statistics for administrative purposes.  Retains necessary documentation in compliance with external and internal regulations.
  • Participates in committees, meetings and conferences as assigned.  Perform other related duties as assigned
  • Assists all MetroPlus departments with resolution of related member retention, utilization management, quality management, customer service, and provider relations concerns.
  • Attends approved in-service and external education and training as per department directives.  
  • Performs other appropriate duties and participates in other special projects as assigned, including, but not limited to, audit review and preparation, quality improvement, community health education, facility/provider relations and marketing activities.
  • Ensures that coordination of membership enrolled in all lines of business is compliant with Federal, State, and City regulations, and are consistent with the Mission, Vision and Values of the organization.

Minimum Qualifications

  • High school diploma and 2 years of satisfactory full-time experience in the areas described, or
  • Bachelor’s degree from an accredited college or university and 1 year of satisfactory full-time work experience. 
  • Excellent interpersonal, organizational communication and analytical skills.
  • Computer literacy with proficiency with Microsoft Office products is required.
  • Bilingual (English/Spanish) is preferred. Fluency in other languages is welcomed.

Professional Competencies: 

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical Skills
  • Written/Oral Communications