Commercial Enrollment & Eligibility Analyst

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

Job summary

MCS Puerto Rico seeks an Eligibility Analyst to analyze and process member eligibility transactions within the Commercial Eligibility unit. You will validate and update member data to ensure accurate coverage and billing information.

The role requires at least six months of enrollment and data entry experience in the health insurance sector, with bilingual Spanish and English capabilities. The position is on-site in San Juan, Puerto Rico.

Qualifications

• Bachelor’s Degree in Healthcare Administration, Business Administration, or related areas.
• At least six (6) months of experience in enrollment and data entry in health insurance.
• Proven experience may be replaced by previously established requirements.

Responsibilities

• Audits and analyzes eligibility discrepancies to validate data.
• Assesses policyholder eligibility history to ensure correct setup.
• Validates coverage, benefits packages, and COBRA/LTD classifications.
• Resolves billing and eligibility errors to enable correct claims processing.
• Handles eligibility maintenance like cancellations, activations, and changes.

Skills

Enrollment processing

Data entry

Audit & analysis

Spanish language

English language

Education

Bachelor’s degree in Healthcare Administration

Associate's degree or 60–64 approved college credits

Job description

GENERAL DESCRIPTION:

Analyzed and processed eligibility transactions and received them in the Commercial Eligibility unit. Validates member eligibility and updates information in the system, as applicable.

Regular
Non-Exempt

GENERAL DESCRIPTION:

Analyzed and processed eligibility transactions and received them in the Commercial Eligibility unit. Validates member eligibility and updates information in the system, as applicable.

ESSENTIAL FUNCTIONS:

• Performs audits and analysis of eligibility discrepancies requested by the Cost Plus, Administrative Services Only, (ASO), and Full Insurance groups to validate the data reflected in MHS and ensure that it contains the correct information.
• Analyzes VIP policyholder eligibility history to determine the conditions under which the policyholder's setup should be reflected in the system.
• Analyzes the insured's requested coverage, family composition ("Tiers"), benefits package, and divisions (COBRA, LTD, Retired, among others) to which the insured belongs to validate and ensure that the information is complete and error-free.
• Analyzes the reporting of coverage, billing, and policyholder setup errors referred by the Billing unit and corrects them in the system so that cases can be billed correctly.
• Evaluates and determines the eligibility rules that apply to the Cost Plus, ASO, and Full Insurance groups, performs data entry in the eligibility system, and creates or updates the Life Insurance screens in the insured's record, as applicable.
• Validates and resolves eligibility situations referred by the Call Center and the department to allow payment of the claim and/or access to benefits through the system.
• Processes eligibility maintenance in the system, such as cancellations, activations, changes, etc., to ensure data integrity.
• Attends to and answers account eligibility questions and handles cancellations, activations, changes, and errors in coverage referred by external customers.
• Communicates with customers to request additional information to complete the eligibility transaction.
• Prepares letters of denials, cancellations, and/or requests for information and submits them to the unit Clerk to be sent to customers upon request.
• Updates the production sheet to report cases worked and provides the status of pending cases to be worked and maintains the confidentiality of information and documents handled.
• 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 Healthcare Administration, Business Administration, or related areas. At least six (6) months of experience in processes related to group and individual enrollment and data entry experience, preferably in the Health Insurance Industry.

OR

Education and Experience:

Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least six (6) months of experience in processes related to group and individual enrollment and data entry experience, preferably in the Health 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 – Intermediate (comprehensive, writing and verbal)

"We are an Equal Employment Opportunity Employer and take affirmative Action to recruit Protected Veterans and Individuals with Disabilities."