Eligibility and Enrollment Analyst

Position Summary:

The Eligibility & Enrollment Analyst is responsible for ensuring the accuracy and integrity of member enrollment and eligibility information across all lines of business, including Medicaid, Marketplace, CHIP and Commercial plans. This role facilitates timely and accurate updates in the health plan operating system, conducts reconciliation processes, resolves enrollment discrepancies, and supports regulatory and operational requirements. The position works closely with internal teams, external vendors, and members to ensure that enrollment data is clean, compliant, and ready for downstream processes.

Qualifications:

• High school diploma or equivalent required; associate or bachelor's degree in business, healthcare administration, or related field preferred.
• Minimum of 2 years of experience in health plan eligibility, enrollment, member services, or related healthcare operations role.
• Experience working with Marketplace, Medicaid, CHIP or Commercial insurance enrollment processes preferred.
• Prior experience with health plan operating systems (e.g., Epic/Tapestry, Softheon) strongly preferred.

Essential Duties and Responsibilities:

Eligibility & Enrollment Processing

• Monitors and processes daily Customer Relationship Management (CRM) and workflow system requests to update member eligibility, demographics, and third-party liability (TPL) coverage.
• Accurately enters, updates, and maintains enrollment information in the health plan operating system (e.g., Epic/Tapestry, Softheon).
• Processes Marketplace enrollment transactions, including plan changes, reactivations, coverage terminations, and life event updates.
• Coordinates with Marketplace Exchange platforms and state agencies to resolve enrollment discrepancies.
• Conducts periodic audits of eligibility data and initiates corrections to ensure regulatory compliance and data integrity.
• CCP liaison to outside customers and clients, such as pharmacy benefit managers and client HR representatives, to resolve urgent member eligibility issues.

Reconciliation & Issue Resolution

• Performs monthly and ad-hoc reconciliation between internal systems, Marketplace enrollment files, Medicaid eligibility feeds, and vendor rosters (e.g., WEX flex card vendor files, OTC vendor Medline).
• Identifies and resolves data mismatches that could impact member benefits, provider payments, or vendor fulfillment.
• Coordinates eligibility file cleanup processes to ensure proper head-of-household assignment for Medicaid flex card distribution, ensuring one card per eligible family unit and correct adult designation.
• Escalates recurring or systemic issues to the Supervisor, Eligibility & Enrollment for resolution planning.

Stakeholder & Member Support

• Responds to inbound calls from members regarding enrollment status, demographic changes and premium billing inquiries.
• Acts as a liaison to external vendors, state agencies, and Marketplace partners for urgent eligibility and enrollment issues.
• Provides timely and professional responses to internal inquiries from Customer Service, Claims, and other operational teams.
• Assists members or their authorized representatives with eligibility-related questions when required.

Operational Support

• Participates in special projects, testing, or system updates related to enrollment processes.
• Assists with inbound or outbound call campaigns as needed.
• Supports quality assurance reviews and maintains documentation for audits and compliance reporting.
• Performs other related duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

• Strong understanding of health insurance eligibility rules, enrollment transactions, and reconciliation processes.
• Familiarity with CMS, state Medicaid, and Marketplace enrollment guidelines.
• Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and ability to navigate multiple systems simultaneously.
• Strong attention to detail and commitment to data accuracy.
• Effective verbal and written communication skills for interacting with internal teams, members, and external partners.
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.
• Problem-solving skills with the ability to identify root causes and propose solutions.
• Demonstrated ability to work both independently and collaboratively within a team.

Work Schedule: Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

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. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Background Screening Notice:

In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at: hhttps://info.flclearinghouse.com