Classicare Enrollment & Elegibility Analyst - Temporary

MCS Puerto Rico; San Juan (PR); On-site; USD 35,000 - 48,000; Full time

Job summary

MCS Puerto Rico is seeking a focused Enrollment Eligibility Specialist to analyze and determine eligibility for Medicare Advantage programs in accordance with CMS, ASEs, and company policies. This temporary, non-exempt role will support enrollment activities in Puerto Rico.

The position requires interpreting enrollment rules, processing documentation, and coordinating with multiple departments. Bilingual Spanish and English capabilities are expected, with a strong emphasis on regulatory

Qualifications

• Education and experience requirements for enrollment processes in Medicare Advantage.
• Experience with enrollment processes in group and individual plans preferred.
• Certifications/licenses: N/A or not required.

Responsibilities

• Process Enrollment, Disenrollment, Cancellation, and Coverage Changes within defined timeframes.
• Evaluate enrollment documents for CMS and ASES compliance and determine eligibility.
• Notify customers and departments when information is missing.
• Ensure notification letters are issued within set periods.
• Monitor LEP, M3P, and ADI processes in related systems.

Skills

Attention to detail

Regulatory compliance

Data entry

Education

Bachelor’s degree

Associate degree or 60-64 credits

High school diploma or technical training

Job description

GENERAL DESCRIPTION:

Responsible for analyzing and assessing prospects’ eligibility for the Medicare Advantage Programs administered by the company. This assessment will be based on the eligibility rules and policies established by the Center for Medicare and Medicaid Services (CMS), Chapters 2 and 3 of the Managed Care Manual, the Puerto Rico Health Services Administration (ASES), the company, and any other regulatory agencies.

Temporary - AEP

Non-Exempt

ESSENTIAL FUNCTIONS

• Receives and processes applications for Enrollment, Disenrollment, Cancellation, and Coverage Changes within defined timeframes.
• Evaluate and analyze enrollment documents to ensure compliance with state, federal, and business regulations, determine prospect eligibility in CMS and ASES systems, enter or correct data in company application systems, and establish applicable eligibility periods.
• Identifying cases with missing information, initiating the returns process, and notifying the customer and the relevant departments.
• Validates reports of cases awaiting information to ensure timely processing in compliance with federal and departmental regulations.
• Ensures that all processed cases have appropriate notification letters within established periods.
• Monitors, analyzes, and documents cases under the Late Enrollment Penalty (LEP), Medicare Prescription Payment Plan (M3P), and Area Deprivation Index (ADI New Members) process in the corresponding systems.
• Provides information and recommendations for action on cases related to enrollment and disenrollment processes.
• Coordinates and approves the sending of Notification Letters resulting from the Primary Care Provider (PCP) transfer process.
• Analyze Capitation and Capitation Adjustment Report rejections referred to the financial department, making necessary adjustments in applicable systems, and reviewing and correcting cases to prevent errors in Capitation payments.
• Handles changes to PCPs in the relevant systems, according to company-approved assignment rules as referred by service areas, providers, or other departments.
• Reconciles the PCPs existing data in all the company systems and makes corrections if discrepancies are identified.
• Responds promptly to service requests from various departments via distribution lists or applications managed by the Unit.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS

Education and experience: Bachelor’s Degree. At least six (6) months of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry.

OR

Education and experience: Associate’s Degree or Sixty to sixty-four (60-64) college credits. At least one (1) year of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry.

OR

Education and Experience: High School Diploma or Technical Course. At least two (2) years of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: N/A

Other: N/A

Languages

Spanish – Intermediate (comprehensive, writing, and verbal)

English – Basic (comprehensive, writing, and verbal)

“We are an Equal Employment Opportunity Employer and take Aff~~?”