Lead Operations Analyst - EDI and Eligibility

Gold Coast Health Plan; California, Camarillo (MO, CA); On-site; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Lead Operations Analyst to oversee eligibility and enrollment processes for Medi-Cal and Medicare members. This pivotal role involves resolving data issues, collaborating with various stakeholders, and ensuring compliance with regulatory standards. The analyst will lead strategic initiatives, manage budgets, and enhance operational efficiency. If you are a skilled communicator with a strong background in health plan services and a passion for improving member experiences, this is the perfect opportunity for you.

Qualifications

• 5+ years of experience in health plan Member Services or enrollment.
• Proficiency in managing eligibility and enrollment processes.

Responsibilities

• Manage eligibility and enrollment processes for Medi-Cal and Medicare members.
• Collaborate with vendors and internal teams for compliance and smooth enrollment.

Skills

Management Skills

Business Acumen

Relationship Building

Customer Orientation

Effective Communication

Diversity Awareness

Analytical Skills

Education

Bachelor's Degree in Business Administration

Bachelor's Degree in Healthcare Administration

Tools

Microsoft Office

Enrollment Software

Job description

Position Summary

The Lead Operations Analyst manages eligibility and enrollment processes for GCHP Medi-Cal and Medicare members, ensuring accurate eligibility files. This role involves resolving membership data issues through identifying business and technical specifications, collaborating with vendors, regulators, healthcare providers, and internal teams to facilitate smooth enrollment and compliance. Responsibilities include reconciling EDI 834 files and overseeing functions such as Enrollment Management, Eligibility Determination, Compliance, Customer Service, Reporting, and Error Resolution. Additional duties may be assigned.

Essential Functions

Includes generating and analyzing reports, documenting operational procedures, leading system requirements and testing, creating user documentation, monitoring system issues, collaborating with technology partners, and managing member enrollment data and inquiries. The role also involves overseeing eligibility verification, supporting outreach, ensuring regulatory compliance, and maintaining documentation for audits. The analyst acts as a business lead on strategic initiatives, manages budgets, and ensures operational efficiency.

Qualifications

Requires management skills, business acumen, relationship building, customer orientation, effective communication, and diversity awareness. A Bachelor's Degree in business administration, healthcare administration, or related field is preferred, with a minimum of 5 years' experience in health plan Member Services, enrollment, or eligibility. Familiarity with health insurance products, strong analytical skills, proficiency in Microsoft Office and enrollment software, and the ability to handle multiple tasks in a fast-paced environment are essential. Experience with Medi-Cal/Medicare is preferred.