Manager, Eligibility & Enrollment

Jobtailor; Deutschland; Remote; EUR 60.000 - 95.000; Vollzeit

Zusammenfassung

Jobtailor is seeking a skilled Enrollment and Eligibility Operations leader to oversee daily workflows across Medicare Advantage enrollments, disenrollments, and plan changes. You will supervise a team, drive quality and production metrics, and coordinate with CMS and internal stakeholders to ensure accurate monthly reconciliation.

Remote role with availability for peak enrollment periods (AEP/OEP). Strong knowledge of CMS guidelines, data analysis, and AI-assisted processes is required; MBA/MHA

Qualifikationen

• 4+ years in Medicare Advantage eligibility and enrollment operations, including 2+ years in a supervisory or team lead role.
• Working knowledge of CMS enrollment and disenrollment regulations for HMO, PPO, SNP products, including election periods and retroactive processing rules.
• Hands-on experience with CMS MARx transaction processing, response and reply file handling, and membership reconciliation.
• Experience supporting CMS or internal audits, including universe preparation and case documentation.
• Strong analytical and root-cause problem-solving skills on complex transaction and eligibility discrepancies.
• Proficiency in Excel and reporting tools for inventory tracking, trend analysis, and audit sampling.
• Ability to learn and build notebooks for metric monitoring and reporting.
• Willingness to work directly in AI-assisted processes under a human-in-the-loop model.
• Effective written and verbal communication, with the ability to explain regulatory requirements to staff and non-technical partners.
• Proven ability to manage competing priorities and high-volume workloads in a deadline-driven, regulated environment.
• Demonstrated commitment to data accuracy and member confidentiality (HIPAA).
• Bachelor's degree in Business, Health Administration, or related field; equivalent experience considered.
• Ability to work remotely with availability to support extended coverage during AEP, OEP, and peak enrollment periods.
• Health plan, MSO, or TPA experience; proficiency with QNXT, Facets, HealthEdge or similar platforms and CMS data exchange tools including HPMS.
• Experience designing or overseeing AI agents in an operational workflow preferred.
• Master's degree (MBA, MHA, or similar) preferred.

Aufgaben

• Manage daily workflow, work queues, and transaction inventory for enrollments, disenrollments, plan changes, cancellations, and retroactive adjustments across HMO, PPO, and SNP products.
• Monitor CMS MARx submissions, response and reply files, and error reports; research and resolve rejections and discrepancies.
• Reconcile membership accurately and on time each month.
• Serve as first escalation point for complex and exception-based cases.
• Supervise, coach, hire, onboard, schedule, and manage performance of Enrollment/Eligibility Associates.
• Set individual production and quality goals tied to department KPIs; own team productivity, quality, engagement, and retention.
• Plan capacity and coverage for AEP, OEP, and Special Election Periods.
• Perform and document quality reviews against CMS guidance and internal controls.
• Support CMS, internal, and external audits by preparing universes, pulling case files, validating samples, and answering auditor questions.
• Execute corrective action plans and close findings on time.
• Translate new CMS guidance and memos into workflow changes, updated job aids, procedures, and staff training.
• Identify recurring errors and rework drivers; implement process improvements and automation opportunities.
• Build and maintain monitoring notebooks and views for volume, aging, throughput, accuracy, timeliness, and reconciliation completion.
• Partner on AI-agent design and use under a human-in-the-loop model, including review requirements, quality checkpoints, controls, and coaching.
• Partner with Member Services, Billing, Data Reconciliation, Compliance, Sales, Agent Support, and Tech on member-impacting issues, defects, interfaces, UAT, upgrades, products, and plan expansions.
• Support the Senior Manager with leadership materials, analysis, CMS inquiries, and governance forums.

Kenntnisse

Medicare Advantage Eligibility

CMS MARx Processing

Team Leadership

Data Analysis

Process Improvement

Excel Proficiency

AI-Assisted Processes

Quality Review

Regulatory Compliance

Effective Communication

Problem-Solving

Time Management

Coaching

Team Collaboration

Ausbildung

Bachelor's degree in Business or Health Administration

Master's degree (MBA, MHA or similar) preferred

Tools

QNXT

Facets

HealthEdge

CMS Data Exchange Tools

HPMS

Jobbeschreibung

• Manage daily workflow, work queues, and transaction inventory for enrollments, disenrollments, plan changes, cancellations, and retroactive adjustments across HMO, PPO, and SNP products
• Monitor CMS MARx submissions, response and reply files, and error reports; research and resolve rejections and discrepancies
• Reconcile membership accurately and on time each month
• Serve as first escalation point for complex and exception-based cases
• Supervise, coach, hire, onboard, schedule, and manage performance of Enrollment/Eligibility Associates
• Set individual production and quality goals tied to department KPIs; own team productivity, quality, engagement, and retention
• Plan capacity and coverage for AEP, OEP, and Special Election Periods
• Perform and document quality reviews against CMS guidance and internal controls
• Support CMS, internal, and external audits by preparing universes, pulling case files, validating samples, and answering auditor questions
• Execute corrective action plans and close findings on time
• Translate new CMS guidance and memos into workflow changes, updated job aids, procedures, and staff training
• Identify recurring errors and rework drivers; implement process improvements and automation opportunities
• Build and maintain monitoring notebooks and views for volume, aging, throughput, accuracy, timeliness, and reconciliation completion
• Partner on AI-agent design and use under a human-in-the-loop model, including review requirements, quality checkpoints, controls, and coaching
• Partner with Member Services, Billing, Data Reconciliation, Compliance, Sales, Agent Support, and Tech on member-impacting issues, defects, interfaces, UAT, upgrades, products, and plan expansions
• Support the Senior Manager with leadership materials, analysis, CMS inquiries, and governance forums

Requirements

• 4+ years in Medicare Advantage eligibility and enrollment operations, including at least 2 years in a supervisory or team lead role
• Working knowledge of CMS enrollment and disenrollment regulations for HMO, PPO, and SNP products, including election periods, effective dating, and retroactive processing rules
• Hands-on experience with CMS MARx transaction processing, response and reply file handling, and membership reconciliation
• Experience supporting CMS or internal audits, including universe preparation and case documentation
• Strong analytical and root-cause problem-solving skills on complex transaction and eligibility discrepancies
• Proficiency in Excel and reporting tools for inventory tracking, trend analysis, and audit sampling
• Ability to learn and build notebooks for metric monitoring and reporting
• Willingness to work directly in AI-assisted processes under a human-in-the-loop model
• Effective written and verbal communication, with the ability to explain regulatory requirements to staff and non-technical partners
• Proven ability to manage competing priorities and high-volume workloads in a deadline-driven, regulated environment
• Demonstrated commitment to data accuracy and member confidentiality (HIPAA)
• Bachelor's degree in Business, Health Administration, or a related field; an equivalent combination of education and directly relevant Medicare enrollment experience will be considered
• Ability to work remotely with availability to support extended coverage during AEP, OEP, and other peak enrollment periods
• Health plan, MSO, or TPA experience preferred, with proficiency in QNXT, Facets, HealthEdge, or similar platforms and CMS data exchange tools including HPMS
• Experience designing or overseeing AI agents in an operational workflow preferred
• Master's degree (MBA, MHA, or similar) preferred

Core Competencies

Demonstrates expertise in Medicare Advantage eligibility and enrollment operations, with a strong focus on compliance with CMS regulations and effective team management. Proficient in data analysis, reporting, and process improvement within a regulated environment.

Highest-signal resume keywords

• Medicare Advantage Eligibility
• CMS MARx Transaction Processing
• Team Leadership
• Data Analysis
• Process Improvement

Hard Skills

• Membership Reconciliation
• Enrollment Regulations
• Audit Support
• Root-Cause Problem Solving
• Excel Proficiency
• Metric Monitoring
• AI-Assisted Processes
• Quality Review
• Corrective Action Plans
• Regulatory Compliance

Soft Skills

• Effective Communication
• Problem-Solving
• Time Management
• Coaching
• Team Collaboration

Industry Keywords

• HMO
• PPO
• SNP
• AEP
• OEP
• Special Election Periods
• HIPAA
• Health Plan
• MSO
• TPA

Tools & Technologies

• QNXT
• Facets
• HealthEdge
• CMS Data Exchange Tools
• HPMS