Classicare Enrollment & Eligibility Analyst

MCS Puerto Rico; San Juan (PR); On-site; USD 42,000 - 54,000; Full time

Job summary

MCS Puerto Rico seeks a detail-oriented enrollment administrator to manage enrollment, disenrollment, eligibility, and benefit maintenance within regulatory guidelines. You will review documents, ensure data integrity, and coordinate with internal stakeholders to resolve issues.

The role requires handling multiple systems, meeting SLAs, and documenting actions for audit readiness. Bilingual English/Spanish capabilities are desired to support diverse member inquiries in Puerto Rico.

Qualifications

• Bachelor’s degree (or equivalent) required; six months of enrollment experience preferred.
• Experience with Medicare Advantage products preferred.
• Spanish and English language requirements noted in the posting.

Responsibilities

• Process enrollment, disenrollment, cancellation, reinstatement, and coverage changes within SLAs and timelines.
• Determine member eligibility and establish effective dates and eligibility periods.
• Identify incomplete applications and initiate return processes with notified departments.

Skills

Enrollment processes

Regulatory compliance

Analytical review

Education

Bachelor's Degree

Associate’s Degree

High School Diploma

Job description

GENERAL DESCRIPTION:

Responsible for the accurate and timely administration of enrollment, disenrollment, eligibility, and benefit maintenance processes in compliance with federal, state, Center for Medicare and Medicaid Services (CMS), Puerto Rico Health Services Administration (ASES), and organizational requirements. Performs analytical review of enrollment transactions, maintains data integrity across multiple systems, and supports operational areas through research, issue resolution, and process coordination.

Regular

Non-Exempt

GENERAL DESCRIPTION:

Responsible for the accurate and timely administration of enrollment, disenrollment, eligibility, and benefit maintenance processes in compliance with federal, state, Center for Medicare and Medicaid Services (CMS), Puerto Rico Health Services Administration (ASES), and organizational requirements. Performs analytical review of enrollment transactions, maintains data integrity across multiple systems, and supports operational areas through research, issue resolution, and process coordination.

ESSENTIAL FUNCTIONS:

• Receives, reviews, and processes enrollment, disenrollment, cancellation, reinstatement, and coverage change requests within established service level agreements (SLAs) and regulatory timeframes.
• Evaluate and analyze enrollment documentation to determine member eligibility, ensure compliance with federal, state, CMS, ASES, and organizational requirements, and establish appropriate effective dates and eligibility periods.
• Identifies applications with missing, incomplete, or inconsistent information; initiates the required return processes and coordinates notifications to members and appropriate departments.
• Reviews and validates pending enrollment and eligibility reports to ensure timely case resolution and compliance with regulatory and departmental requirements.
• Ensures all processed transactions are supported by the appropriate member notifications and correspondence within established regulatory timeframes.
• Investigates enrollment and eligibility issues and provides recommendations for resolution to internal stakeholders, leadership, and operational departments.
• Conducts research and performs data validation activities to identify, analyze, and correct eligibility, enrollment, and demographic discrepancies.
• Responds to inquiries and service requests from internal departments through designated applications, distribution lists, and workflow management systems.
• Maintains accurate documentation of actions taken and ensures compliance with audit, quality assurance, and regulatory requirements
• Processes PCP assignment and reassignment requests in accordance with established policies, provider network requirements, and company-approved assignment rules.
• Reconciles PCP information across multiple organizational systems and databases to ensure accuracy, consistency, and data integrity.
• Participates in departmental projects, process improvement initiatives, system testing, and operational readiness activities as assigned.
• 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: Not required.

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 Affinative Action to recruit Protected Veterans and Individuals with Disabilities.”