Analista Senior De Afiliación Y Elegibilidad Classicare
Regular
Non-Exempt
GENERAL DESCRIPTION:
Serves as a subject matter expert responsible for overseeing enrollment and eligibility processes, ensuring compliance with federal, state, and organizational guidelines. Supports operational excellence through advanced analysis, quality assurance, training, and process improvement initiatives.
ESSENTIAL FUNCTIONS:
- Identifies risk factors and areas of opportunity based on monthly metrics and internal audit results and develops targeted training to address gaps and strengthen team performance.
- Assist leadership with special projects, system enhancements, and implementation of new processes.
- Act as a subject matter expert (SME) for enrollment, disenrollment, and eligibility processes, guiding analysts and cross-functional teams.
- Ensure compliance with the Center of Medicare and Medicaid Services (CMS), state regulations, and internal policies, maintaining high standards of accuracy and timeliness.
- Manage and monitor specialized processes such as Late Enrollment Penalty (LEP), Out of Area (OFA) Disenrollment, and Grievance and Appeals referrals.
- Support and lead training sessions for new hires and temporary staff during Annual Enrollment Period/Open Enrollment Period (AEP/OEP).
- Monitor and track cases requiring additional information and manage incomplete application processes (documentation, notifications, follow-ups).
- Review, analyze, and process enrollment transactions (enrollments, disenrollments, cancellations, reinstatements, product changes) within regulatory timelines.
- Evaluate enrollment documentation submitted by Sales Representatives and brokers to ensure completeness and regulatory adherence.
- Determine member eligibility using systems and perform data entry and corrections.
- 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: Health Services, Healthcare Administration or related fields. At least one (1) year of experience in enrollment, eligibility, customer service, or healthcare operations, including processing enrollment and disenrollment transactions.
OR
Education and Experience: Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least two (2) years of experience in enrollment, eligibility, customer service, or healthcare operations, including processing enrollment and disenrollment transactions.
OR
Education and Experience: High School Diploma or Technical Course. At least three (3) years of experience in enrollment, eligibility, customer service, or healthcare operations, including processing enrollment and disenrollment transactions.
"Proven experience may be replaced by previously established requirements"
Certifications / Licenses: Not required.
Other: Knowledge of Advantage products is preferred.
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.”
