Health Plan Enrollment Representative

Summary / Duties

Health Plan Enrollment Representative supports the client’s enrollment operations by preparing, processing, uploading, and maintaining member and group registration information in enrollment databases.

• Entering new enrollments and terminations
• Updating demographic and PCP information
• Verifying eligibility status
• Resolving discrepancies
• Analyzing transactional data
• Submitting retroactive eligibility changes when needed

This role responds to eligibility inquiries, generates member correspondence, processes duplicate ID card requests, reviews enrollment submissions for accuracy, and communicates with brokers, customers, vendors, Member Services, and internal teams to obtain missing information or resolve file issues.

• Supports data audits
• Supports inventory control
• Supports regulatory compliance
• Supports PHI protection
• Supports open or annual enrollment readiness

Requirements

• HS diploma or equivalent education/experience
• 1+ year recent relevant experience in health plan enrollment, eligibility, insurance, or healthcare operations
• Experience with member/group enrollment, terminations, demographic updates, PCP changes, and eligibility verification
• Experience reconciling eligibility discrepancies, reviewing pending enrollment data, and processing retroactive eligibility changes
• Proficiency in Microsoft Office Suite, including Excel, Word, and PowerPoint
• Experience with database management, data validation, enrollment system uploads, and file layouts
• Able to maintain PHI confidentiality and follow audit controls, production standards, and regulatory requirements
• Able to communicate with brokers, customers, vendors, internal teams, and Member Services to resolve enrollment issues

Preferred Requirements

• Working knowledge of health insurance enrollment and eligibility practices
• Familiarity with DMHC regulations, managed care, reimbursement models, payer relationships, and pricing mechanisms
• Experience with Microsoft Access, SQL Server, spreadsheet solutions, or FSA file layouts
• Strong attention to detail, organization, time management, and ability to manage multiple priorities
• Analytical, negotiation, and project coordination skills