ENROLLMENT QUALITY AUDITOR

Accountabilities: • Audit enrollment, disenrollment, eligibility, and plan or PCP change transactions processed for assigned health plan customers. • Follow established customer quality processes, audit tools, and rebuttal procedures to ensure consistent and well-documented reviews. • Review 834 enrollment file transactions and coordinate with state enrollment systems and enrollment brokers to verify member effective dates, retroactive enrollment and disenrollment actions, and eligibility segments. • Verify timely and accurate processing of Medicaid eligibility redeterminations and recertifications against CMS and applicable state Medicaid timeliness standards. • Audit dual-eligible Medicare-Medicaid enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits. • Communicate audit findings to individual enrollment associates and collaborate with Team Leads and operational managers to identify errors, trends, and opportunities for improvement. • Compile and report individual and team quality assurance performance results to management and relevant employees. • Provide feedback to Training teams and operational leaders to improve processing instructions and identify refresher training requirements. • Participate in Audit the Auditor programs to validate audit accuracy and consistency. • Participate in semi-annual or annual auditor calibration activities to maintain consistent quality standards. • Maintain current knowledge of CMS Medicaid managed care enrollment guidelines, state-specific enrollment requirements, and managed long-term care (MLTC) enrollment and disenrollment rules. • Analyze contractual SLAs and KPIs, particularly those related to enrollment processing accuracy and timeliness. • Collaborate effectively with remote colleagues, client audit teams, and operational leadership across multiple time zones. Requirements: • High school diploma or GED required. • At least 3 years of experience in health plan enrollment and eligibility auditing operations. • Previous Medicaid managed care enrollment auditing experience is preferred. • Experience with managed long-term care (MLTC) or dual-eligible Medicare-Medicaid enrollment is strongly preferred. • Strong understanding of health plan enrollment, eligibility processing, quality assurance, and transaction auditing. • Familiarity with EDI 834 enrollment transactions and eligibility verification systems is a plus. • Experience with HealthRules Payor or GuidingCare is preferred. • Proficiency with Microsoft Office, particularly Excel, PowerPoint, and Outlook. • Ability to interpret and analyze contractual SLAs, KPIs, and enrollment processing requirements. • Strong analytical skills and exceptional attention to detail, with the ability to identify processing errors and quality trends. • Excellent written and verbal communication skills, particularly when delivering constructive feedback and explaining audit findings. • Ability to work independently with limited supervision while also contributing effectively within a remote team environment. • Strong organizational and time-management skills, with the ability to manage multiple priorities and meet deadlines. • Willingness to maintain current knowledge of changing CMS, state Medicaid, and managed-care enrollment requirements. Benefits: • Annual base salary of $44,000–$50,000. • Full-time, permanent employment. • Fully remote work within the United States. • Flexible collaboration across multiple time zones. • Opportunities to contribute directly to enrollment quality, healthcare operations, and member eligibility accuracy. • Exposure to Medicaid managed care, CMS requirements, state enrollment systems, and healthcare technology operations. • Opportunities for professional development through audit calibration, cross-functional collaboration, and specialized healthcare operations experience. How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether?    Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.     #LI-CL1