DescriptionPosition SummaryThe Discrepancy Resolution Team Lead manages the team responsible for identifying, investigating, and resolving complex Medicare enrollment and eligibility discrepancies. This position oversees daily operations related to CMS and carrier enrollment data, ensuring compliance with CMS regulations while delivering timely, accurate resolution of membership issues.
The Team Lead serves as the primary escalation point for complex eligibility cases, partners with internal departments and external carrier organizations, and provides leadership to the Discrepancy Resolution team to drive operational excellence, quality, and member satisfaction.
Essential Duties & ResponsibilitiesLeadership & Team Management- Lead, mentor, coach, and develop the Discrepancy Resolution team to ensure high-quality performance and professional growth.
- Monitor team productivity, quality, and turnaround times.
- Conduct regular performance reviews, provide coaching, and identify training opportunities.
- Establish workflows and best practices to improve operational efficiency and accuracy.
- Serve as the primary escalation point for complex eligibility and enrollment issues.
Discrepancy Resolution & Operations- Oversee detailed audits of CMS and carrier enrollment files, including Transaction Reply Reports (TRRs), to identify and resolve eligibility and membership discrepancies.
- Ensure timely investigation and resolution of discrepancies involving Medicare Part A, Part B, Medicaid, Dual Eligible status, Low-Income Subsidy (LIS), and Special Enrollment Periods (SEPs).
- Monitor reconciliation activities to ensure accurate member eligibility and enrollment records across internal systems and carrier platforms.
- Maintain compliance with CMS regulations, carrier policies, and organizational procedures.
Member & Carrier Support- Oversee member outreach regarding disenrollment, reinstatement opportunities, eligibility requirements, and coverage corrections.
- Ensure team members communicate Medicare regulations, enrollment timelines, and documentation requirements accurately, professionally, and compassionately.
- Partner with carrier organizations, onboarding teams, account management, and compliance to resolve complex membership issues.
- Build strong relationships with carrier contacts to facilitate timely issue resolution.
Process Improvement & Reporting- Develop and maintain standard operating procedures (SOPs) for discrepancy resolution processes.
- Monitor operational metrics and prepare reports identifying trends, root causes, and opportunities for process improvement.
- Recommend system enhancements and workflow improvements to reduce enrollment errors and improve member experience.
- Participate in cross-functional initiatives supporting enrollment accuracy, compliance, and operational excellence.
RequirementsQualifications- Bachelor's degree or equivalent combination of education and relevant healthcare experience.
- Ability to get NJ Healthcare License within 90 days of hire (external)
- 5+ years of Medicare enrollment, eligibility, discrepancy resolution, or healthcare operations experience.
- 2+ years of leadership or supervisory experience preferred.
- Strong knowledge of CMS Medicare enrollment regulations, eligibility requirements, and enrollment processes.
- Experience working with CMS Transaction Reply Reports (TRRs), eligibility files, and carrier enrollment systems.
- Experience resolving complex Medicare eligibility and enrollment issues.
- Strong analytical, organizational, and problem-solving skills.
- Excellent verbal and written communication skills, including experience handling sensitive member conversations.
- Proficiency with Microsoft Excel, Microsoft Office Suite, and enrollment management systems.
Preferred Qualifications- Experience working with Medicare Advantage and Prescription Drug Plans.
- Knowledge of CMS enrollment systems, MARx, TRRs, and Medicare eligibility processing.
- Experience with quality assurance, auditing, and operational reporting.
- Experience leading healthcare operations or enrollment teams.
