Medicare Enrollment Reconciliation Specialist I

Date: Jan 24, 2023

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 7848 


Position Summary/Position


Under direction of the Core Business Systems Management, Medicare Enrollment Reconciliation Specialist I is responsible for the support functions related to the Medicare Eligibility processing and reconciliation, implementation, configuration and on-going maintenance of IEHP Core systems and alignment with the Medicare software along with other application programs. This position is responsible for timely enrollment submission files to CMS and timely processing of CMS eligibility files including member correspondence generation. This position will run monthly revenue reconciliation focusing on membership accuracy in preparation to Quarterly CMS Member Data Attestation in coordination with the Finance team.

Major Functions (Duties and Responsibilities)


1. Ensure compliance with regulatory entities such as but not limited to Medicare Center of Medicare Services (CMS) and Medi-Cal Department of Health Care Services (DHCS).
2. Develop a comprehensive understanding of application features within the Medicare Software system and capabilities in order to provide effective support to the user community.
3. Identify and analyze current IEHP business processes and requirements to support implementation and configuration activities.
4. Ensure accurate and timely processing of enrollment file processing (whether automated or manual) and CMS transaction reply reports for IEHP’s Medicare program(s). As part of the CMS file processing, ensure regulatory response transactions are sent to CMS along with required member correspondence sent to members. 
5. Interact professionally with internal customers by answering questions and inquiries, professionally representing the department to others, referring inquires, and generating telephone or written responses to inquiries while following the company mission and commitment for improvement. 
6. Execute application-testing new/revised development and application upgrades/code push activities within the Medicare software.
7. Resolve finance discrepancies identified via the Revenue Reconciliation Process by submitting discrepancies to the Retroactive Processing Contractor (RPC).
8. Thoroughly document inconsistencies/ issues/ concerns for follow-up and /or resolution by internal support staff or the software vendor.
9. Track the status of assigned tasks and / or related problem issues for completion.
10. Assist in the coordination of data analysis related to configuration or issue assessment.
11. Aid in the development and maintenance of policies and procedures related to job functions, application configuration, general usage of supported systems and application maintenance.
12. Monitor incoming requests for potential impact and coordinate awareness of changes.
13. Demonstrate a commitment to support IEHP’s strategic priorities to become a 5-Star Health Plan and incorporate LEAN principles into daily work.
14. Demonstrate commitment to Team Member Engagement by participating in projects/tasks/activities that promote Team Member excitement and enthusiasm for their role, increased work effort, and commitment to the organization.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Leading: Self

Experience Qualifications


Three (3) years in Medicare and/or Medi-Cal eligibility processing.

Preferred Experience


Experience working with Medicare/Medicaid government programs preferred. Experience working with CMS contracted vendors (for example Processing Contractor (RPC), ECRS or MARx) preferred. Workfront reporting experience preferred.

Education Qualifications


High school diploma or GED required.

Preferred Education


Bachelor’s degree from an accredited institution preferred.

Professional Certification

Professional Licenses

Drivers License Required


Knowledge Requirement


Knowledge of Managed Care systems and client/server applications preferred. Knowledge of health plan business operations preferred. Principles and methods of systems analysis for data processing required. Project management understanding and skills preferred. Principles of sound testing methodologies preferred.

Skills Requirement


Proficient in Microsoft Office Suite programs including Visio required. Excellent written, and oral communication skills required. Sound research techniques preferred. Proven analytical and problem-solving capabilities required.

Abilities Requirement


Ability to work independently, under pressure, balances multiple projects and deadline driven required. Ability follow-through and track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed timely required. Ability to grasp new ideas and concepts quickly required. Ability to successfully present ideas in an audience-oriented manner required. Ability to manage multiple projects of varying complexity, priority levels and deadlines required.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Word processing and data entry involving computer keyboard and screens.


Position is eligible for telecommuting/remote work location model upon completing the necessary steps and receiving HR approval. The incumbent approved to telecommute may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs determined by IEHP leadership.

Work Model Location


Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY
Use of computer mouse - FREQUENTLY
Hearing: Over the Telephone/Cell Phone - FREQUENTLY
Hearing: Conference Speakers/Video Calls/Radio Calls - FREQUENTLY
Keyboarding: 10-Key - FREQUENTLY
Hearing: In a group - FREQUENTLY
Communicate: Information/ideas verbally - CONSTANTLY
Alternate Sit/Stand or Walk at Will - CONSTANTLY
Near Visual Acuity - CONSTANTLY
Perform complex and varied tasks - FREQUENTLY
Develop and maintain positive work relationships - CONSTANTLY
Regular contacts: co-workers, supervisor - CONSTANTLY
Decision-making - FREQUENTLY
Lead/Influence Others - FREQUENTLY
Work review - FREQUENTLY

A reasonable salary expectation is between $51,833.60  - $64,022.40, based upon experience and internal equity


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 7,000 and a team of more than 2,500 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles