Eligibility Specialist

Green Key Resources; New York (NY); Hybrid; USD 170,000 - 210,000; Full time

Job summary

Green Key Resources is seeking an experienced Director of Eligibility Operations to lead enrollment and eligibility for a large multi-employer benefit fund in the region.

The role oversees a sizable Eligibility Operations team, ensures compliance with ERISA, CMS/MSP, HCRA and CBA requirements, manages member appeals with General Counsel, and partners with IT on system upgrades, data migrations, and testing in a hybrid onsite/remote environment.

Qualifications

• 8+ years of senior-level Eligibility & Enrollment experience in health insurance or benefits.
• 6+ years of supervisory/management experience leading large, diverse teams.
• Bachelor's degree in Business Management, Health Administration, or related field; Master's preferred.
• Knowledge of ERISA, CMS/MSP, and HCRA regulations.

Responsibilities

• Oversee and develop a large Eligibility Operations team, including management and line staff.
• Drive strategic planning, process improvement, operational efficiency, and succession planning.
• Oversee eligibility and enrollment processes for members and dependents.
• Serve as a subject matter expert on ERISA, CMS/MSP, HCRA, and CBA requirements.
• Manage member appeals in partnership with General Counsel.
• Oversee CMS Medicare Secondary Payer (MSP) Section 111 reporting and HCRA Covered Lives Assessments.
• Lead administration and optimization of enterprise eligibility systems.
• Partner with IT on system upgrades, data migrations, UAT, and regression testing.
• Ensure data integrity across TPAs, PBMs, Medicare Advantage Plans, employer portals, and member portals.
• Oversee eligibility audits, quality controls, remediation plans, and vendor reconciliation.
• Present operational metrics and recommendations to executive leadership and Board Trustees.
• Manage department budgets and identify opportunities for cost and process improvements.

Skills

Leadership

Analytical thinking

Communication

Organizational skills

Education

Bachelor's degree in Business Management, Health Administration, or related field

Master's degree preferred

Tools

Vitech-V3locity

Job description

We are seeking an experienced Director of Eligibility Operations to lead enrollment and eligibility operations for one of the largest multi-employer benefit funds in the region.

This is a high-impact senior leadership role overseeing the enrollment of members, spouses, and dependents for health and welfare benefits while ensuring compliance with complex CBA and regulatory requirements.

What You'll Lead

• Oversee and develop a large Eligibility Operations team, including management and line staff
• Drive strategic planning, process improvement, operational efficiency, and succession planning
• Oversee eligibility and enrollment processes for members and dependents
• Serve as a subject matter expert on ERISA, CMS/MSP, HCRA, and CBA requirements
• Manage member appeals in partnership with General Counsel
• Oversee CMS Medicare Secondary Payer (MSP) Section 111 reporting and HCRA Covered Lives Assessments
• Lead administration and optimization of enterprise eligibility systems
• Partner with IT on system upgrades, data migrations, UAT, and regression testing
• Ensure data integrity across TPAs, PBMs, Medicare Advantage Plans, employer portals, and member portals
• Oversee eligibility audits, quality controls, remediation plans, and vendor reconciliation
• Present operational metrics and recommendations to executive leadership and Board Trustees
• Manage department budgets and identify opportunities for cost and process improvements

What We're Looking For

• Bachelor's degree in Business Management, Health Administration, or related field; Master's preferred
• 8+ years of senior-level Eligibility & Enrollment experience within health insurance or benefits
• 6+ years of supervisory/management experience leading large, diverse teams
• Strong knowledge of ERISA, CMS/MSP, and HCRA regulations
• Experience with Vitech-V3locity or a similar enterprise eligibility system strongly preferred
• Strong understanding of multi-employer benefits and Collective Bargaining Agreements
• Excellent analytical, organizational, communication, and leadership skills
• Ability to translate complex eligibility, regulatory, and operational data into actionable recommendations for senior leadership

Why Consider This Opportunity?

This is a highly visible leadership position with the opportunity to shape eligibility operations, technology, compliance, and member service for a large-scale benefits organization. The role offers a strong compensation package and the potential for a hybrid schedule after an initial onsite period.