Manager, Eligibility & Enrollment

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee daily workflow, manage work queues, and control transaction inventory for enrollments, disenrollments, plan modifications, cancellations, and retroactive adjustments across HMO, PPO, and SNP products.

• Track CMS MARx submissions, response and reply files, and error reports; investigate and resolve rejections and discrepancies.

• Ensure accurate and timely reconciliation of membership each month.

• Act as the primary escalation point for complex and exception-based cases.

• Supervise, mentor, recruit, onboard, schedule, and assess the performance of Enrollment/Eligibility Associates.

• Establish individual production and quality objectives linked to departmental KPIs; take ownership of team productivity, quality, engagement, and retention.

• Strategize capacity and coverage for AEP, OEP, and Special Election Periods.

• Conduct and document quality reviews in accordance with CMS guidelines and internal controls.

• Assist with CMS, internal, and external audits by preparing datasets, retrieving case files, validating samples, and responding to auditor inquiries.

• Implement corrective action plans and ensure timely closure of findings.

• Interpret new CMS guidelines and memos to inform workflow modifications, updates to job aids, procedures, and staff training.

• Identify recurring errors and factors leading to rework; initiate process enhancements and automation opportunities.

• Develop and maintain monitoring systems and dashboards for volume, aging, throughput, accuracy, timeliness, and reconciliation completion.

• Collaborate on AI-agent design and utilization within a human-in-the-loop framework, including review requirements, quality checkpoints, controls, and coaching.

• Work in partnership with Member Services, Billing, Data Reconciliation, Compliance, Sales, Agent Support, and Technology on member-related issues, defects, interfaces, UAT, upgrades, products, and plan expansions.

• Assist the Senior Manager with leadership materials, analysis, CMS inquiries, and governance forums.

⛳️ Requirements

• Minimum of 4 years in Medicare Advantage eligibility and enrollment operations, including at least 2 years in a supervisory or team lead capacity.

• Comprehensive understanding of CMS enrollment and disenrollment regulations for HMO, PPO, and SNP products, including election periods, effective dating, and retroactive processing rules.

• Practical experience with CMS MARx transaction processing, response and reply file management, and membership reconciliation.

• Background in facilitating CMS or internal audits, including universe preparation and case documentation.

• Strong analytical and root-cause problem-solving abilities for complex transaction and eligibility discrepancies.

• Proficient in Excel and reporting tools for inventory management, trend analysis, and audit sampling.

• Capability to learn and develop notebooks for metric monitoring and reporting.

• Willingness to engage directly with AI-assisted processes within a human-in-the-loop model.

• Excellent written and verbal communication skills, with the capacity to convey regulatory requirements to staff and non-technical stakeholders.

• Proven track record of managing multiple priorities and high-volume workloads in a deadline-driven, regulated setting.

• Strong commitment to data accuracy and safeguarding member confidentiality (HIPAA).

• Bachelor’s degree in Business, Health Administration, or a related discipline; a comparable combination of education and relevant Medicare enrollment experience will be accepted.

• Ability to work remotely with the flexibility to support extended hours during AEP, OEP, and other peak enrollment times.

• Preferred experience in health plans, MSOs, or TPAs, with proficiency in QNXT, Facets, HealthEdge, or similar platforms, as well as CMS data exchange tools like HPMS.

• Desired experience in designing or overseeing AI agents within operational workflows.

• A Master’s degree (MBA, MHA, or similar) is preferred.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plan with minimal or no premium.

• Generous paid time off policy.

• Monthly stipend of $100 for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, excluding Director-level and above.

• Parental leave program.

• 401K program.