Manager, Government Enrollment & Appeals

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

📋 Description

• Manages enrollment and billing operations for Medicare Advantage, Medicare Supplement, CHIP, and ACA products, ensuring precise eligibility, premium billing, member maintenance, and ongoing operational efficiency.

• Oversees Medicare Advantage appeals and grievances, ensuring prompt and compliant resolution of member and provider appeals and grievances in line with CMS guidelines.

• Guarantees adherence to federal and state regulations, including CMS and relevant program requirements, through effective management of policies, procedures, controls, and regulatory reporting.

• Directs activities related to reconciliation, quality, and performance monitoring concerning enrollment, billing, and Medicare Advantage appeals, identifying trends, risks, and opportunities for enhancement.

• Leads efforts for audit preparedness and regulatory support, including responses to CMS audits, compliance reviews, and internal oversight activities related to enrollment, billing, and Medicare Advantage appeals and grievances.

• Collaborates across functions with Compliance, Claims, Customer Service, Sales, Product, Finance, IT, and other stakeholders to resolve intricate operational issues and ensure alignment across the enterprise.

• Champions process improvement initiatives to boost accuracy, efficiency, member experience, and regulatory outcomes across all assigned functions.

⛳️ Requirements

• 5 years of experience in one or more areas including enrollment, billing, or reconciliation.

• 1 year of experience in a staff, team lead, or project lead capacity.

• Proven experience in managing health insurance enrollment and billing operations.

• Experience in overseeing Medicare Advantage Appeals and Grievances or related regulatory functions.

• Background in supporting compliance activities, audits, and operational improvement initiatives.

• Knowledge of enrollment and billing operations across Medicare and Individual market products.

• Comprehensive understanding of Medicare Advantage appeals and grievance regulations and processes.

• Familiarity with CMS compliance, audit, and oversight expectations.

• Understanding of managed care operational workflows and cross-functional dependencies.

• Bachelor's degree in business, Health Care Administration, or a related field, or an equivalent combination of education and experience.

🏝️ Benefits

• Medical, Dental & Vision coverage

• Retirement Plan

• Generous time off including Paid Time Off

• Holidays

• Volunteer time off

• Incentive Plan

• Tuition Reimbursement

• More