Enrollment Specialist II

HealthEdge; United States; Remote; USD 40,000 - 44,000; Full time

Job summary

HealthEdge is seeking an Enrollment Specialist II to ensure accurate enrollment, billing, and maintenance of member data across CMS transactions in a remote US role. You will verify eligibility, review Medicaid/enrollment guidelines, resolve system rejections, and reconcile CMS membership reports.

The position requires collaboration with teammates, training completion, and a proactive approach to quality. Applicants should have a high school diploma and 3-5 years in processing Medicare

Qualifications

• High school degree required
• 3-5 years of professional experience in processing Medicare enrollment transactions
• Understanding of Medicare Advantage products, CMS transaction files, and enrollment-related guidelines; Medicaid enrollment experience a plus
• Experience with CMS interfaces and systems for managing Medicare Advantage enrollment and billing functions
• Ability to analyse enrollment reconciliation data and report SLAs, KPIs, and other operations reports
• Willingness to learn
• Team collaborator
• Strong work ethic

Responsibilities

• Be responsible for preparing, processing, and maintaining enrollment and disenrollment requests
• Verify and maintain all applicable eligibility requirements
• Review and process CMS transactions
• Review Medicaid eligibility and complete verification processes
• Resolve enrollment system rejections based on regulatory and client guidelines
• Reconcile membership reports as required by CMS
• Attend and complete trainings scheduled by the client and employer
• Mentor junior team members
• Collaborate on special projects (documentation, training, quality reviews)
• Maintain communication with management to address issues and ensure case accuracy and quality
• Participate in projects and perform other duties as assigned

Job description

Overview

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

HealthEdge is looking for an Enrollment Specialist II, reporting to the Enrollment Manager. The Enrollment Specialist II is responsible for ensuring accurate enrollment including billing and maintenance of member data by researching and resolving enrollment and billing discrepancies. The role is also responsible for reconciling and correcting enrollment-related issues by building case files that are sent to the CMS Contractor for approval and resolution.

As an Enrollment Specialist II at HealthEdge, this is your opportunity to

• Be responsible for preparing, processing, and maintaining enrollment and disenrollment requests
• Be responsible to verify and maintain all applicable eligibility requirements
• Be responsible to review and process CMS transactions
• Be responsible for reviewing Medicaid eligibility and completing verification processes
• Be responsible to resolve enrollment system rejections based on regulatory and client specified guidelines
• Be responsible to reconcile membership reports as required by CMS
• Be accountable to attend and successfully complete the trainings scheduled by the client and employer
• Mentor junior members of the team
• Collaborate with other team members on special projects; special projects can include process documentation development, training, quality reviews for the client(s), or any other project as determined by management
• Establish and maintain an appropriate level of communication with management to address issues and concerns and take preventive measures that ensure case accuracy and quality
• Participate in projects as assigned by management
• Perform other duties as assigned

You bring:

• High school degree required
• 3-5 years of professional experience in processing Medicare enrollment transactions
• A thorough understanding of Medicare Advantage products, CMS transaction files, and the corresponding enrollment-related guidelines; Medicaid enrollment experience a plus
• Experience with CMS interfaces and systems for managing the Medicare Advantage enrollment and billing functions
• Ability to analyse enrollment reconciliation data and report SLAs, KPIs, and other operations reports and present findings in a structured way
• Willingness to learn
• Team collaborator
• Strong work ethic

For this role, we value:

• The ability to adapt quickly to a challenging environment
• A self-starter and quick learner
• Ability to collaborate

Geographic Responsibility: Remote, US

Type of Employment: Full-time, permanent

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• Work across multiple time zones in a hybrid or remote work environment.
• Long periods of time sitting and/or standing in front of a computer using video technology.
• May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

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**The annual US base salary range for this position is $40,000 to $44,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will bedeterminedduring the interview process and is based on a combination of factors including, but not limited to,your skills, experience,qualificationsand education.