Enrollment Analyst - ACA Enrollment

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Come join our Peak Health team at WVU Medicine as an Enrollment Analyst, contributing to the foundation for an innovative, new health plan. This position will report to the Enrollment Manager, playing a unique and important role in our mission to change healthcare for the better.
Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient enrollment team. The enrollment team will review, execute, and oversee the processing of member enrollment application information for Peak Health’s Plan Suite. The Enrollment Analyst role will have responsibilities pertaining to Medicare and ASO business functions. This role will be responsible for managing weekly enrollment files, daily processing of Medicare applications, reconciliation of membership and coverage records, overseeing member record maintenance, complying with submissions to CMS, and work closely with the leadership team to create and maintain training programs for enrollment specialists.
This role will be responsible for completing inventory in a production environment, as well as offline projects. An individual who is self-guided and able to work with minimal supervision will be successful in this role.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High school Diploma or equivalent

EXPERIENCE:

1. Three (3) years of experience working with medical or institutional data entry.

2. Three (3) years of customer service experience.

3. Two (2) years of Medicare eligibility and Medicare Enrollment processing experience

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Four (4) years of Medicare Enrollment processing and customer service experience.

2. Familiarity with Medicare elections, transaction codes, and reconciliation operations.

3. Familiarity with managing late enrollment penalty (LEP) for MAPD enrollees.

4. Familiarity with navigating CMS tools and resources, particularly the MARx website.

5. At least one (1) year of experience with system/user acceptance testing.

6. At least one (1) year of experience with developing and delivering trainings.

7. Familiarity with Enrollment Data Validations (EDVs) and REED Submissions.

8. Previous experience in EMR systems.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Determine accuracy and completions of member form information. Entry/verifies form data.

2. Resolves enrollment issues to assure efficient and seamless member experience. 

3. Maintains member enrollment records annually, indicating changes, updates, and outreach as required.

4. Meets all production and quality standards, maintaining workqueues according to department standards.

5. Effectively communicates with internal and external staff.

6. Elevates issues to next level of supervision, as appropriate.

7. Ensures accuracy of data entered and record maintenance.

8. Attends all required training classes, demonstrating proficiency and ability to learn.

9. Manages coordination of benefits (COB) on member records, running real-time eligibility queries, as needed.

10. Develops and Delivers department trainings to new hires, including managing the resources available to staff.

11. Participates in system testing for any development rollouts.

12. Participates in department planning to ensure a successful Open Enrollment.

13. Fully owns the enrollment data validation (EDV) monthly processes and REED submissions.

14. Fully owns monthly reconciliation processes from CMS.

15. Fully owns completion of LEP data files and MPWR files.

16. Participates in both ASO & Medicare job duties.

17. Processes SNP applications, verifying eligibility, including but not limited to Dual-Entitlement and residence within the service area.

18. Manage and process member enrollment applications, ensuring accurate and timely entry into the system.

19. Analyze enrollment data to identify trends, discrepancies, and areas for improvement; prepare reports for management review.

20. Ensure adherence to federal and state regulations regarding member enrollment; conduct regular audits to maintain compliance standards.

21. Respond to inquiries from potential and existing members regarding enrollment procedures, benefits, and eligibility requirements.

22. Maintain and update enrollment databases and software; troubleshoot system-related issues as needed.

23. Work closely with cross-functional teams, including underwriting, billing, and customer service, to streamline the enrollment process and resolve issues.

24. Participate in process improvement initiatives to enhance the efficiency and effectiveness of the enrollment function

25. Other duties as deemed appropriate by the Management Team.

SKILLS AND ABILITIES:

1. Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

2. Ability to take direction and to navigate through multiple systems simultaneously.

3. Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette

4. Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.

5. Familiarity with Medical insurance enrollment processes.

6. Familiarity with ASO/Commercial and Medicare enrollment processes.

7. Familiarity with coordination of benefits (COB) payment orders and Tapestry’s automatic filing order (AFO) table.

8. Ability to be a self-starter and work with minimal input from management team.

9. Requires exceptional attention to detail, the ability to be organized and to be able to perform multiple tasks simultaneously.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit for extended periods of time.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)

2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access) Internet Explorer and EPIC

3. Excellent planning, communication, documentation, analytical, and problem-solving abilities.

4. Must possess strong interpersonal, organizational, and project management skills with the ability to work on
multiple tasks simultaneously.

Additional Job Description:

• Processes ACA/FFM enrollment transactions, including new enrollments, maintenance transactions, cancellations, terminations, reinstatements, and plan changes.
• Reviews and resolves enrollment discrepancies received through the Federally Facilitated Marketplace (FFM), ensuring compliance with CMS Marketplace requirements.
• Validates applicant eligibility information received through Marketplace enrollment files, including household information, coverage effective dates, and enrollment status.
• Processes and researches Special Enrollment Period (SEP) requests and supporting documentation in accordance with CMS Marketplace guidelines.
• Maintains accurate Advance Premium Tax Credit (APTC) and Cost-Sharing Reduction (CSR) information on member records and researches discrepancies as needed.
• Performs reconciliation of Marketplace enrollment transactions, identifying, researching, and resolving variances between issuer and CMS records.
• Reviews and processes 834 enrollment transaction files and resolves transaction errors, rejects, and exceptions.
• Monitors enrollment work queues to ensure Marketplace enrollment transactions are completed within CMS and organizational timeliness standards.
• Coordinates with internal departments, Marketplace representatives, vendors, and external stakeholders to resolve complex enrollment issues.
• Assists with annual Marketplace Open Enrollment and Special Enrollment Period operational readiness activities.
• Participates in user acceptance testing (UAT) and validation activities related to ACA/Marketplace system enhancements and regulatory changes.
• Ensures compliance with CMS Marketplace regulations, issuer guidelines, and internal policies governing ACA enrollment processing.
• Identifies enrollment trends, recurring issues, and process improvement opportunities to improve operational efficiency and member experience.
• Maintains documentation of enrollment procedures, job aids, and standard operating procedures related to Marketplace operations.

Preferred Qualifications (Replaces Medicare Experience above):

• Three (3) or more years of ACA/Marketplace enrollment processing experience.

• Experience working with Federally Facilitated Marketplace (FFM) enrollment operations.

• Familiarity with Health Insurance Marketplace eligibility and enrollment regulations.

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2902 PHH Claims Operations