Eligibility Specialist

Washington Health Benefit Exchange

The mission of Washington Health Benefit Exchange (Exchange) is to radically improve how Washington residents secure health insurance through innovative and practical solutions, an easy-to-use customer experience, our values of integrity, respect, equity and transparency, and by providing undeniable value to the health care community. The Exchange is a public-private partnership that operates Washington Healthplanfinder, the eligibility and enrollment portal used by one in four Washington residents to obtain health and dental coverage. Through this platform, and with support from a Customer Support Center and statewide network of in-person navigators and brokers, individuals and families can shop, compare and enroll in private, qualified health plans (as defined in the Affordable Care Act) or enroll in Washington Apple Health, the state Medicaid program.

The Exchange embraces the following equity statement adopted by our Board of Directors: Equity is fundamental to the mission of the Washington Health Benefit Exchange. The process of advancing toward equity and becoming anti-racist is disruptive and demands vigilance to dismantle deeply entrenched systems of privilege and oppression. While systemic racism is a root cause of many societal inequities, we must also use an intersectional approach to address all forms of bias and oppression, which interact with and often exacerbate racial inequities. To be successful, we must recognize the socioeconomic drivers of health and focus on people and places where needs are greatest. As we listen to community, we must hold ourselves accountable to responding to recommendations to remedy inequitable policies, systems, or practices within the Exchange's area of influence. Our goal is that all Washingtonians have full and equal access to opportunities, power and resources to achieve their full potential.

The Washington Health Benefit Exchange (Exchange) receives thousands of applications for health insurance coverage each day via Washington Healthplanfinder. Using facts, discretion, and independent judgment, this position makes qualitative decisions regarding legal and regulatory compliance with the Affordable Care Act (ACA) by determining coverage and/or subsidy eligibility for customers who applied for health insurance through Healthplanfinder. This includes reviewing documentation to verify citizenship, lawful presence, tribal enrollment, incarceration status, social security number, eligibility for other minimum essential coverage (MEC), and income attestations(s). The incumbent must determine the customer's eligibility for tax credits and/or enrollment in a qualified health or dental plan in accordance with the ACA, regulations, laws, policies, and established business processes. In addition, the incumbent will be expected to actively participate in quality assurance checks of eligibility rules, policies, guidance, and processes in our efforts to achieve continuous improvement.

Duties

Working knowledge of the Affordable Care Act, Medicaid, the commercial health insurance market, and Federal and State subsidy programs. Maintain a working knowledge and understanding of conditional eligibility verification regulations, laws, policies and guidance, and operation of the prescribed computer programs. Use and manage multiple complex computer systems and databases simultaneously to make accurate determinations regarding the customer's lawful presence or citizenship status, income, social security number, incarceration status, tribal enrollment, and access to other, minimum essential coverage. Explain complex requirements and federally mandated timelines to customers who have minimal understanding of the ACA, the health insurance landscape, and/or may have limited English language proficiency. Validate and reconcile customer-supplied documents against customer attestation. Determine whether customer-supplied documentation is acceptable or fails to enable verification of eligibility and send written correspondence to customers notify them of the determination. Adhere to changes in Federal regulations, state law, and WAHBE policies that dictate eligibility for job functions and duties. Work independently and manage the workload to meet agreed upon timelines, deliverables, and performance measures. Perform complex mathematical calculations to validate customer's attestation of income and/or eligibility and amount of Advance Premium Tax Credits (APTC), cost sharing reductions, and/or Cascade Care Savings. Use appropriate template language in routing situations and draft unique letters as necessary to communicate clearly and effectively, written and orally, with coworkers, external partners such as brokers and navigators, and customers. Demonstrate awareness of potential cultural, linguistic, and/or accessibility differences. Assist customers in accordance with policies, business processes, laws, and regulations, reporting changes and making corrections to their Healthplanfinder applications when appropriate and in accordance with policies, procedures, business processes, and federal regulations. Respond equitably and with cultural sensitivity to complex eligibility questions that are unable to be answered by first and second-level customer service representatives. Participate in discussions and offer suggestions to improve conditional eligibility verification and policies. Crosstrain and provide back-up support, as needed, to other Eligibility Specialists, Program/Eligibility Coordinator, and Appeals Specialists.

Qualifications

Required: High School Diploma or equivalency. Two (2) years of experience explaining and applying complex regulations, laws and policies in a state, federal, health insurance or financial industry. One (1) year of demonstrated experience performing complex mathematical calculations, and strong attention to detail. Working knowledge of health care, health insurance, and Federal and State subsidy eligibility. Recognition and understanding of historical barriers to accessibility, and lasting impacts of inaccessibility. Maintain a working knowledge and understanding of conditional eligibility verification regulations, laws, policies and guidance, and operation of the prescribed computer programs. Ability to use Microsoft Office Software, including Teams, Outlook, SharePoint, Word, and PowerPoint, as well as complex spreadsheets, to include MS Excel, APTC Calculator and Income Averaging Calculator (or similar standard business tool). Understanding of historical, current and ongoing changes in the health care industry and barriers. Demonstrated experience working independently, able to manage multiple projects efficiently, adapt to changing workload, and communicate effectively with stakeholders regarding deadlines. Demonstrated ability to use tools/information to solve problems. Systematic approach to researching, prior to making determinations, and/or asking for a second opinion if unsure. Effective communication oral/written while using appropriate language in routine situations, ability to adapt depending on the receiver and knowledge level. Mindful awareness of potential cultural, linguistic and or accessibility differences. Demonstrated experience protecting sensitive information (PII) and maintaining confidentiality. Demonstrated ability to communicate effectively with customers and co-workers, both orally and in writing, regarding complex or sensitive information or issues. Make accurate, independent assessments and calculations to ascertain validity of submitted documentation. Desired: Demonstrated experience as a Team player, able to communicate effectively and clearly. Experience utilizing active listening skills. Ability to adapt to changing workload and priorities and offer feedback on processing expectations. Understanding of the eligibility determination components in the Affordable Care Act and particularly an understanding of advance premium tax credits (APTC). Ability to research and apply policies, business processes, and federal regulations as they relate to eligibility.