Job Details

This is a remote position; Candidates MUST reside in California.

We are looking for someone who has supervisory experience, along with Medicare experience enrolling members into health plans.

What You Will Be Doing

Under general supervision, the Enrollment & Eligibility Supervisor supervises the daily operations of the Medicare (D-SNP) Enrollment Unit and the Medi-Cal Eligibility Unit. This role ensures member enrollment and eligibility data is maintained accurately and in alignment with CMS, DHCS, and Health Plan guidelines, as well as contractual and regulatory requirements. Work is moderately complex and requires a sound understanding of enrollment processes, regulatory standards, and systems. The position exercises a moderate degree of independent judgment and discretion and provides day-to-day guidance and oversight to staff responsible for processing member transactions.

Supervises

• Enrollment Clerks
• Eligibility Clerks

Essential Functions

• Monitor daily operations of both the Medicare (D-SNP) Enrollment Unit and the Medi-Cal Eligibility Unit to ensure compliance with CMS, DHCS, and Health Plan policies, procedures, and timelines.
• Oversee and prioritizes work assignments, resolving workload conflicts and ensuring adequate coverage and resource allocation.
• Verifies and maintains enrollment files, reconciles key reports, manually processes changes, and handles routine and non-routine enrollment and eligibility issues in collaboration with the eligibility unit staff.
• Supervise the accurate processing of enrollment transactions, eligibility determinations, and ongoing member maintenance, including additions, terminations, and demographic changes.
• Coordinate resolution of enrollment and eligibility discrepancies by working with internal systems (e.g., QNXT, EAM) and external partners (e.g., CMS, counties, DHCS).
• Review and reconcile state and federal eligibility data files (834s, MEDS, MMR, MARx) to maintain accurate membership records.
• Conducts daily and monthly quality audits of enrollment and eligibility activities; identifies discrepancies requiring escalation; develops and maintains performance dashboards and productivity tracking templates.
• Collaborates with leadership to identify and address training needs; develops and facilitates routine and ad hoc training.
• Collaborates with interdepartmental units to improve workflows and processes, resolving issues and making recommendations as necessary.
• Serves as subject matter expert and business process lead for special projects related to enrollment and eligibility processes, including IT system implementation or enhancement.
• Implements and maintains unit guidelines, policies and procedures; recommends revisions; communicates changes timely and effectively.
• Prepares for and participates in regulatory audits and develops and monitors audit corrective action plans for timely resolution.
• Creates, maintains and distributes required reports to internal stakeholders and regulatory bodies.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of eligibility and coordination of benefit requirements for healthcare enrollment.
• Basic knowledge of and ability to implement internal audit processes.
• Basic knowledge of and ability to maintain records according to established accounting principles and CMS regulatory requirements.
• Basic knowledge of automated transaction systems for membership and enrollment recordkeeping, including efficient data entry, uploading, and extraction.
• Basic data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems, and recognize and act on trends.
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Ability to read, comprehend and apply complex written documents.
• Interacts effectively with individuals both inside and outside of Health Plan; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills, with the ability to communicate professionally and effectively with internal and external Constant sitting; frequent standing and walking; frequent repetitive motion; frequent talking and listening in person and over the phone; occasional bending and stooping; occasional handling of materials up to 25 lbs.; close up and distance vision requirements.al stakeholders.
• Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meet deadlines.
• Ability to support the development and delivery of relevant and effective training materials.
• Intermediate skills in Word and Excel.
• Ability to handle confidential information with appropriate discretion.
• Ability to speak, read, write, and be understood in English.

What You Have

Education and Experience

Required

• High school diploma or equivalent; and
• At least four years' experience in enrollment/disenrollment roles with a Medicare Advantage health plan; and
• At least five years of progressively responsible experience in health plan enrollment and eligibility operations, including experience with Medi-Cal and/or Medicare (D-SNP) regulatory requirements and serving in a lead or senior role coordinating team activities, supporting operational oversight, resolving escalated issues, and supporting staff development.

What You Will Get

HPSJ Perks

• Competitive salary
• Robust and affordable health/dental/vision with choices in providers
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee's birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you're commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.