What are the responsibilities and job description for the Benefit Eligibility Auditor position at TX Health Benefits Pool?

SUMMARY

Performs routine benefit plan eligibility audits. These audits include member and dependent eligibility, qualifying life event (QLE), and waiver requests. Work involves reviewing eligibility rules to determine whether individuals are entitled to participate in the plan. This may include reviewing various employee or dependent eligibility records, which may include birth certificates, marriage licenses, divorce decrees, adoption records and other eligibility documentation. Work may also involve investigative work to determine qualifying life events are consistent with the benefit changes made. Works under moderate supervision, with some latitude for the use of initiative and independent judgment.

The ideal candidate for this position will have strong attention to detail, have a solid understanding of eligibility and Section 125 rules and regulations, have the ability to diffuse difficult or challenging conversations, be an advanced user of Excel, and have strong verbal and written communication skills.

ESSENTIAL DUTIES AND RESPONSIBILITIES may include the following. Other duties may be assigned:

Responsible for Actively at Work responsibilities including but not limited to

Taking ownership of inquires and driving them to efficient and effective resolutions

Acting as the liaison between TXHB and the customer(s) for all inquiries

Documenting and managing all communication and documentation received

Participating in and leading AAW related meetings as needed

Appling eligibility and general benefits knowledge to inquires

Perform routine audits of Qualifying Life Events to ensure requested changes are consistent with changes made.

Performs routine audits on waiver reasons to ensure we have obtained appropriate documentation to support to the waiver.

Performs routine dependent eligibility documentation audits.

Performs audits and reconciles eligibility data with internal and external vendors to ensure accuracy for benefit access.

Participates in the set up of new and renewing member groups.

Educates members on eligibility requirements, actively at work requirements, audit processes, and related matters.

Serve as a subject matter expert on benefit eligibility issues, providing guidance to Benefit Coordinator advocates and other staff as needed.

KNOWLEDGE/SKILLS/ABILITIES

Advanced knowledge of benefit terminology and TXHB benefits design.

Expert knowledge of eligibility requirements including Section 125 rules.

Knowledge of COBRA, FMLA, and leave administration practices.

Strong knowledge of MS Office and billing and enrollment software.

Advanced Excel skills.

Familiarity with Quality Assurance procedures and standards in a Billing and Eligibility environment

Ability to make independent decisions and draw conclusions from data and trends.

Ability to write reports and correspondence.

Ability to document procedures.

Effectively communicate complex benefits administration subjects both verbally and in writing

Effective time management, organization, and prioritization skills.

Ability to work in team environment and perform multi-task job functions.

Strong service-oriented communication skills.

Ability to convey a professional manner in dealing with others and maintain constructive working relationships.

Self-motivated to fulfill tasks and meet deadlines.

Ability to effectively work within rapidly changing circumstances as needed.

EDUCATION/EXPERIENCE

Required

Graduation from an accredited four-year college or university with major coursework in business administration, insurance, or a related field is generally preferred. Experience and education may be substituted for one another.

Two or more years of experience interpreting and applying Section 125 rules and analyzing benefits data.

Preferred

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ability to speak/hear clearly to communicate by phone or in person.

Ability to frequently stand, sit and walk.

Ability to frequently lift and/or move up to 15 pounds.

Prolonged periods of sitting at a desk and working on a computer.

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Benefit Eligibility Auditor

What are the responsibilities and job description for the Benefit Eligibility Auditor position at TX Health Benefits Pool?

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