Note: The job is a remote job and is open to candidates in USA. Pinnacle Technology is seeking a Medicare Advantage Premium Billing Analyst to support Medicare Advantage Prescription Drug enrollment operations. The role manages enrollment transactions, reconciles data, resolves EDI and regulatory discrepancies, coordinates benefits, supports process improvements and audits, and collaborates with internal and external stakeholders.
Responsibilities
- Perform and support all aspects of Medicare enrollment operations , including enrollment, disenrollment, cancellations, changes, and reconciliation
- Process and validate MAPD member enrollment transactions and related eligibility information
- Analyze and reconcile enrollment data to identify and resolve discrepancies
- Work with 834 EDI enrollment files , including reviewing, validating, researching, and resolving enrollment-related errors
- Work with California DHS/state enrollment files and processes
- Work with CMS enrollment files, systems, and regulatory requirements
- Support Medicare and Medicaid enrollment and eligibility activities
- Perform benefits coordination and research enrollment-related issues
- Investigate enrollment discrepancies and determine appropriate corrective actions
- Maintain enrollment data integrity and ensure transactions comply with applicable regulatory requirements
- Analyze reports, trends, and enrollment data to identify operational issues and opportunities for improvement
- Support business analysis, workflow improvements, and process-improvement initiatives
- Collaborate with internal departments, business partners, state agencies, CMS, and other stakeholders to resolve enrollment issues
- Maintain accurate documentation, procedures, and operational records
- Prioritize and manage multiple assignments while meeting established deadlines and service-level expectations
- Support audits, compliance activities, and regulatory requirements as needed
- Perform other enrollment operations duties as assigned
Skills
- 3–5 years of direct Medicare Advantage Prescription Drug Plan (MAPD) experience
- 3–5 years of experience in a Medicare health plan or managed care environment involving enrollment, disenrollment, and reconciliation
- Hands-on experience with California DHS enrollment files/processes — required
- Experience working with 834 EDI enrollment files — required
- Strong knowledge of CMS enrollment processes, files, and regulatory requirements
- Strong understanding of Medicare enrollment and billing regulatory requirements
- Experience with Medicare and Medicaid enrollment
- Experience with enrollment reconciliation and benefits coordination
- High School Diploma or equivalent required
- Working knowledge of Microsoft Excel, Word, and PowerPoint
- Experience with data analysis and/or data visualization tools
- Strong critical-thinking, analytical, and problem-solving skills
- Ability to prioritize multiple assignments in an environment with frequently changing priorities and deadlines
- Strong understanding of healthcare and managed care operations
- Demonstrated reliability and ability to consistently meet required scheduling standards
- Experience with business analysis and process improvement
- Experience supporting enrollment system implementations, testing, or workflow enhancements
- Experience troubleshooting enrollment data and EDI discrepancies
- Experience working with CMS and state regulatory agencies
- Experience with managed care MSO operations
- Experience developing reports, procedures, job aids, or operational documentation
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