Eligibility and Enrollment Specialist

Healthy Alliance • Schenectady, NY

2d • Hybrid

About The Position

The Eligibility and Enrollment Specialist supports contracted partners, community members, providers, and managed care organizations (MCOs) throughout eligibility and enrollment processes. The role answers questions and ensures accurate information about eligibility and prior authorization requirements so eligible Medicaid Members can access services in a timely manner. It serves as a link between health-related social needs (HRSN) providers and the people they support, applying program requirements and communicating compassionately with community members and their care teams.

The position manages enrollment, eligibility, and prior authorization activities; validates Medicaid eligibility; maintains accurate records; coordinates with internal departments and external partners; and supports service authorization reviews and appeals. It also monitors enrollment data to help identify community members who need screening outreach and escalates potential compliance risks.

The role involves primarily remote work with some office-based time in a hybrid environment. Work is sedentary and primarily involves sitting or standing and using typical office equipment, including a computer, laptop, and cell phone. The position may involve access to protected health information and must follow applicable company policies and HIPAA regulations. Salary is $52,950–$60,892 per year, commensurate with experience.

Requirements

• High school diploma or equivalent.
• In-depth knowledge of federal, state, and local guidelines and ability to interpret and operationalize NYSDOH guidelines for HRSN service management.
• Strong working knowledge of program eligibility criteria for successful enrollment in HRSN services.
• Knowledge of policy changes and updates for accurate eligibility determinations and program integrity.
• Ability to manage a high-volume workload, review complex cases, and make decisions based on eligibility criteria.
• Familiarity with social services or benefits administration.
• Effective questioning and active listening to gather applicant information for eligibility decisions.
• Strong customer service skills and ability to handle sensitive conversations respectfully and empathetically.
• Strong critical-thinking, decision-making, communication, and documentation skills.
• Ability to contribute individually to key performance metrics.
• Ability to manage challenging conversations, multitask, prioritize work, perform data entry, and maintain attention to detail.
• Ability to work effectively in a hybrid environment requiring primarily remote work with some office-based time.
• Experience with MS Office Suite, including Word, Excel, PowerPoint, and Outlook, and with Zoom/Teams.
• Ability to perform work in accordance with Healthy Alliance core competencies and values.

Nice To Haves

• Postsecondary education in Social Work, Human Services, Public Health, Healthcare Administration, or a related field.
• Coursework in communication, data management, and policy analysis.
• Experience with Managed Care Organizations (MCOs) and/or case management.
• Familiarity with social services, public benefits, or healthcare programs.
• Equivalent combination of education and experience will be considered.

Responsibilities

• Serve as the primary point of contact for internal teams, network providers, MCOs, Medicaid Members, and other external stakeholders for enrollment, eligibility, and prior authorization activities.
• Handle enrollment and eligibility phone calls and emails, answer questions, solve problems, and facilitate access to care for eligible Medicaid Members and their care teams.
• Validate Medicaid Member enrollment and eligibility through NYSDOH’s Medicaid Eligibility Verification System (MEVS) and/or Electronic Provider Assisted Claim Entry System (ePACES), and assign Members to an established care team provider.
• Verify and reconcile enrollment and eligibility file data, identify discrepancies, and ensure accurate records.
• Liaise between internal departments, including Operations and Finance, and MCOs to ensure eligibility discrepancies are updated.
• Manage enrollment and eligibility changes, documenting and communicating updates to Social Care Navigators, enhanced HRSN service providers, MCOs, and other SCNs.
• Facilitate eligibility determinations for HRSN services using established NYSDOH eligibility criteria.
• Manage SCN-required prior authorizations for designated enhanced HRSN services according to NYSDOH guidelines and SCN workflows.
• Monitor enrollment and eligibility data to identify unassigned or disengaged community members for screening outreach.
• Maintain accurate, up-to-date enrollment, eligibility, and prior authorization documentation needed before HRSN services are provided.
• Support the Compliance team’s review and management of service authorizations, post-service/pre-payment reviews, and appeals or service reconsiderations from Medicaid Members denied assistance.
• Escalate potential compliance risks to Performance Management and/or the VP of Compliance and Privacy, as appropriate.
• Perform work in accordance with Healthy Alliance core competencies and values and applicable company policies and procedures.

Benefits

• Competitive compensation package.
• Comprehensive insurance benefits available the first of the month after hire, including medical, dental, vision, group short-term disability, and life insurance with buy-up options.
• Flexible spending and HSA company-contributed accounts.
• 401(k) with company match.
• Unlimited paid time off after 90 days of employment.
• Company-sponsored training and certification opportunities.
• Hybrid work environment and people-first workplace.
• Amenities, professional development opportunities, events, and programming.
• Workplace that values safety, respect, employee engagement, recognition, and diversity.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED