Job DescriptionA bit about this role:Our Eligibility & Enrollment team is the front door to the member experience - we process every enrollment, disenrollment, plan change, and retroactive adjustment across our HMO, PPO, and Special Needs Plan products, and we own the CMS transactions that make membership accurate and auditable. As Manager, you'll turn departmental strategy into daily workflows, production targets, and staff assignments, keeping the work compliant with CMS requirements and on time.
You'll report to the Senior Manager, Eligibility & Enrollment and lead a team of Enrollment/Eligibility Associates. This is a hands-on operational leadership role: you'll be in the queues, in the data, and in the escalations, while building the reporting and controls the team runs on. Your results show up directly in CMS transaction accuracy and timeliness, inventory aging, quality audit scores, and the member experience measures tied to enrollment accuracy.
Your responsibilities and impact will include:- Managing daily workflow, work queues, and transaction inventory so enrollments, disenrollments, plan changes, cancellations, and retroactive adjustments across HMO, PPO, and SNP products clear within CMS and internal SLAs, holding aging and backlog inside established thresholds.
- Monitoring CMS MARx submissions, response and reply files, and error reports so rejections and discrepancies are researched and resolved inside required timeframes, and membership reconciliation lands accurate and on time each month.
- Serving as the first point of escalation on complex and exception-based cases, making case-level decisions consistent with CMS guidance and internal policy.
- Supervising, coaching, and developing associates - hiring, onboarding, scheduling, one-on-ones, performance management, and individual production and quality goals tied to department KPIs - and owning the team's productivity, quality, engagement, and retention. You'll set the tone for accountability and service excellence, and address performance or conduct issues promptly and consistently.
- Planning capacity and coverage for peak cycles, including AEP, OEP, and Special Election Periods, so volume surges don't become backlog.
- Performing and documenting quality reviews of transactions and member records against the CMS Medicare Managed Care Enrollment and Disenrollment Guidance and internal controls, and driving individual and team audit scores.
- Supporting CMS, internal, and external audits by preparing universes, pulling case files, validating samples, and answering auditor questions; executing assigned corrective action plans and closing them on time, with no repeat findings in your area.
- Translating new CMS guidance and memos into operational changes - recommending workflow updates to the Senior Manager, keeping job aids and desk-level procedures current, and training staff on regulatory changes and system enhancements.
- Identifying recurring errors, rework drivers, and manual workarounds, then implementing process improvements and automation opportunities.
- Building and maintaining notebooks and monitoring views for volume, aging, throughput, accuracy, timeliness, and reconciliation completion, and escalating trends and risks with a recommended action rather than just a number.
- Partnering with peer managers and staff on the design and use of AI agents in transaction processing under a human-in-the-loop model: defining where human review is required, setting quality checkpoints on agent-assisted output, documenting controls to audit standards, and coaching the team against over-reliance on automated output.
- Partnering with Member Services, Billing, Data Reconciliation, Compliance, Sales, Agent Support, and Tech on member-impacting issues, defect resolution, file transmission and interface monitoring, and UAT for configuration changes, upgrades, new products, and plan expansions.
- Supporting the Senior Manager with materials and analysis for leadership, CMS inquiries, and internal governance forums.
Required skills and experience:- 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, with proficiency in Excel and reporting tools for inventory tracking, trend analysis, and audit sampling.
- Demonstrated aptitude for hands-on operational tooling - including the ability to learn and build notebooks for metric monitoring and reporting - and 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, with a 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.
Desired skills and experience:- Health plan, MSO, or TPA experience, with proficiency in a health plan administration platform (QNXT, Facets, HealthEdge, or similar) and CMS data exchange tools including HPMS.
- Experience designing or overseeing AI agents in an operational workflow; master's degree (MBA, MHA, or similar)
Salary range: $73,000 - $114,000 / year
The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.
Our Total Rewards package includes:
- Employer sponsored health, dental and vision plan with low or no premium
- Generous paid time off
- $100 monthly mobile or internet stipend
- Stock options for all employees
- Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
- Parental leave program
- 401K program
- And more....
*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.
