Manager, Eligibility & Enrollment

• Manage daily workflow, work queues, and transaction inventory for enrollments, disenrollments, plan changes, cancellations, and retroactive adjustments across HMO, PPO, and SNP products
• Monitor CMS MARx submissions, response and reply files, and error reports; research and resolve rejections and discrepancies
• Reconcile membership accurately and on time each month
• Serve as first escalation point for complex and exception-based cases
• Supervise, coach, hire, onboard, schedule, and manage performance of Enrollment/Eligibility Associates
• Set individual production and quality goals tied to department KPIs; own team productivity, quality, engagement, and retention
• Plan capacity and coverage for AEP, OEP, and Special Election Periods
• Perform and document quality reviews against CMS guidance and internal controls
• Support CMS, internal, and external audits by preparing universes, pulling case files, validating samples, and answering auditor questions
• Execute corrective action plans and close findings on time
• Translate new CMS guidance and memos into workflow changes, updated job aids, procedures, and staff training
• Identify recurring errors and rework drivers; implement process improvements and automation opportunities
• Build and maintain monitoring notebooks and views for volume, aging, throughput, accuracy, timeliness, and reconciliation completion
• Partner on AI-agent design and use under a human-in-the-loop model, including review requirements, quality checkpoints, controls, and coaching
• Partner with Member Services, Billing, Data Reconciliation, Compliance, Sales, Agent Support, and Tech on member-impacting issues, defects, interfaces, UAT, upgrades, products, and plan expansions
• Support the Senior Manager with leadership materials, analysis, CMS inquiries, and governance forums

Requirements

• 4+ years in Medicare Advantage eligibility and enrollment operations, including at least 2 years in a supervisory or team lead role
• Working knowledge of CMS enrollment and disenrollment regulations for HMO, PPO, and SNP products, including election periods, effective dating, and retroactive processing rules
• Hands-on experience with CMS MARx transaction processing, response and reply file handling, and membership reconciliation
• Experience supporting CMS or internal audits, including universe preparation and case documentation
• Strong analytical and root-cause problem-solving skills on complex transaction and eligibility discrepancies
• Proficiency in Excel and reporting tools for inventory tracking, trend analysis, and audit sampling
• Ability to learn and build notebooks for metric monitoring and reporting
• Willingness to work directly in AI-assisted processes under a human-in-the-loop model
• Effective written and verbal communication, with the ability to explain regulatory requirements to staff and non-technical partners
• Proven ability to manage competing priorities and high-volume workloads in a deadline-driven, regulated environment
• Demonstrated commitment to data accuracy and member confidentiality (HIPAA)
• Bachelor's degree in Business, Health Administration, or a related field; an equivalent combination of education and directly relevant Medicare enrollment experience will be considered
• Ability to work remotely with availability to support extended coverage during AEP, OEP, and other peak enrollment periods
• Health plan, MSO, or TPA experience preferred, with proficiency in QNXT, Facets, HealthEdge, or similar platforms and CMS data exchange tools including HPMS
• Experience designing or overseeing AI agents in an operational workflow preferred
• Master's degree (MBA, MHA, or similar) preferred

Core Competencies

Demonstrates expertise in Medicare Advantage eligibility and enrollment operations, with a strong focus on compliance with CMS regulations and effective team management. Proficient in data analysis, reporting, and process improvement within a regulated environment.

Highest-signal resume keywords

• Medicare Advantage Eligibility
• CMS MARx Transaction Processing
• Team Leadership
• Data Analysis
• Process Improvement

Hard Skills

• Membership Reconciliation
• Enrollment Regulations
• Audit Support
• Root-Cause Problem Solving
• Excel Proficiency
• Metric Monitoring
• AI-Assisted Processes
• Quality Review
• Corrective Action Plans
• Regulatory Compliance

Soft Skills

• Effective Communication
• Problem-Solving
• Time Management
• Coaching
• Team Collaboration

Industry Keywords

• HMO
• PPO
• SNP
• AEP
• OEP
• Special Election Periods
• HIPAA
• Health Plan
• MSO
• TPA

Tools & Technologies

• QNXT
• Facets
• HealthEdge
• CMS Data Exchange Tools
• HPMS