Classicare Enrollment & Eligibility Senior Analyst

MCS Puerto Rico; San Juan (PR); On-site; USD 42,000 - 64,000; Full time

Job summary

MCS Puerto Rico seeks a subject matter expert to oversee enrollment and eligibility processes, ensuring CMS and state compliance while guiding analysts and cross-functional teams.

You will lead training, monitor monthly metrics, perform data analysis, and drive process improvements through QA initiatives and special projects during enrollment cycles.

Qualifications

• Bachelor’s Degree in a relevant field with 1+ year in enrollment, eligibility, or healthcare operations.
• Experience processing enrollment and disenrollment transactions.
• Knowledge of CMS guidelines and regulatory requirements.

Responsibilities

• Identify risk factors and opportunities using monthly metrics and audits.
• Develop targeted training to close gaps and improve performance.
• Serve as SME for enrollment, disenrollment, and eligibility processes.
• Ensure compliance with CMS, state regulations, and internal policies.
• Manage LEP, OFA Disenrollment, and Grievance/Appeals referrals.
• Lead training for new hires during AEP/OEP periods.
• Review enrollment transactions within regulatory timelines.
• Evaluate enrollment documentation for completeness and adherence.
• Determine member eligibility using systems and perform data corrections.

Skills

Subject matter expert

Training delivery

Quality assurance

Process improvement

Data analysis

Metrics interpretation

Education

Bachelor’s Degree in Business Administration, Health Services, Healthcare Administration or related fields

Associate's Degree or 60-64 college credits

High School Diploma or Technical Course

Job description

GENERAL DESCRIPTION

Serves as a subject matter expert responsible for overseeing enrollment and eligibility processes, ensuring compliance with federal, state, and organizational guidelines. Supports operational excellence through advanced analysis, quality assurance, training, and process improvement initiatives.

EMPLOYMENT TYPE

Regular

Non-Exempt

ESSENTIAL FUNCTIONS

• Identifies risk factors and areas of opportunity based on monthly metrics and internal audit results, and develops targeted training to address gaps and strengthen team performance.
• Assist leadership with special projects, system enhancements, and implementation of new processes.
• Act as a subject matter expert (SME) for enrollment, disenrollment, and eligibility processes, guiding analysts and cross-functional teams.
• Ensure compliance with the Center of Medicare and Medicaid Services (CMS), state regulations, and internal policies, maintaining high standards of accuracy and timeliness.
• Manage and monitor specialized processes such as Late Enrollment Penalty (LEP), Out of Area (OFA) Disenrollment, and Grievance and Appeals referrals.
• Support and lead training sessions for new hires and temporary staff during Annual Enrollment Period/Open Enrollment Period (AEP/OEP).
• Monitor and track cases requiring additional information and manage incomplete application processes (documentation, notifications, follow-ups).
• Review, analyze, and process enrollment transactions (enrollments, disenrollments, cancellations, reinstatements, product changes) within regulatory timelines.
• Evaluate enrollment documentation submitted by Sales Representatives and brokers to ensure completeness and regulatory adherence.
• Determine member eligibility using systems and perform data entry and corrections.
• 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 in Business Administration, Health Services, Healthcare Administration or related fields. At least one (1) year of experience in enrollment, eligibility, customer service, or healthcare operations, including processing enrollment and disenrollment transactions.

OR

Education and Experience: Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least two (2) years of experience in enrollment, eligibility, customer service, or healthcare operations, including processing enrollment and disenrollment transactions.

OR

Education and Experience: High School Diploma or Technical Course. At least three (3) years of experience in enrollment, eligibility, customer service, or healthcare operations, including processing enrollment and disenrollment transactions.

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

Certifications / Licenses: Not required.

Other: Knowledge of Advantage products is preferred.

Languages: Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take affirmative action to recruit protected veterans and individuals with disabilities.”