Eligibility and Enrollment Analyst

South Florida Community Care Network•Sunrise, FL

4d•Hybrid

About The Position

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.

Requirements

High school diploma or equivalent required
Minimum of 2 years of experience in health plan eligibility, enrollment, member services, or related healthcare operations role.
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.
Candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

Nice To Haves

Associate or bachelor’s degree in business, healthcare administration, or related field preferred.
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.
Strong understanding of health insurance eligibility rules, enrollment transactions, and reconciliation processes.
Familiarity with CMS, state Medicaid, and Marketplace enrollment guidelines.

Responsibilities

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.
Acts as CCP liaison to outside customers and clients, such as pharmacy benefit managers and client HR representatives, to resolve urgent member eligibility issues.
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.
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.
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.