Health Plan Specialist REMOTE

AcuteCare Health System LLC•Oceanport, NJ

1d•Remote

About The Position

The Health Plan Specialist is responsible for supporting enrollment, eligibility, revenue operations, and data analysis across PACE programs. This role ensures accurate, compliant, and timely management of Medicare, Medicaid, and self-pay participant enrollment. This role is expected to investigate, own, and drive resolution of complex enrollment and eligibility issues through to completion. This position serves as a key liaison between Revenue Cycle, local PACE sites, and external stakeholders, ensuring alignment across enrollment workflows, regulatory requirements, and financial outcomes. The role combines hands-on operational execution with data-driven analysis and process improvement.

Requirements

Bachelor’s degree preferred or equivalent experience
2–4+ years of experience in healthcare operations, managed care, PACE, or eligibility/enrollment
Strong knowledge of: Medicare and Medicaid eligibility, enrollment processes and regulatory requirements, health plan revenue cycle fundamentals
Experience working across multiple states preferred
Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.

Responsibilities

Ensure accurate and timely enrollment and disenrollment of participants across Medicare, Medicaid, and self-pay lines of business
Validate participant eligibility and maintain supporting documentation in compliance with internal policies and regulatory requirements
Identify and drive resolution of discrepancies impacting eligibility, coverage, and enrollment status
Manage enrollment and eligibility data files and data transfer processes supporting PACE operations (e.g., CMS, state submissions, internal systems)
Review and troubleshoot enrollment transactions and data files to identify errors, rejects, and inconsistencies
Monitor enrollment trends, data accuracy, and operational metrics to support decision-making
Communicate with state agencies, CMS, and vendors regarding eligibility, enrollment issues, and regulatory requirements
Research and document state-specific eligibility rules and enrollment workflows; provide recommendations for operational improvements
Ensure alignment between eligibility status and revenue capture processes
Coordinate with revenue cycle, finance, and local PACE programs to identify, track, and resolve issues involving patient liability, share of cost, Medicare Only, and self-pay obligations
Assist in resolving discrepancies related to eligibility, coverage, or billing
Identify, track, and resolve issues that may result in lost or delayed revenue (e.g. enrollment gaps, eligibility mismatches)
Support reconciliation of enrollment data against capitation, billing, and payment records
Serve as a liaison between Revenue Cycle and local PACE programs
Provide reporting and actively participate in regular meetings with sites to review enrollment, eligibility, and financial performance metrics
Provide training and guidance to site staff on enrollment processes, eligibility requirements, and health plan workflows
Support cross-functional collaboration to ensure consistent execution across all programs
Support regulatory and internal audits, including One-third financial audits, Medicare Part D function and audits, Enrollment Data Verification (EDV), and State and CMS program reviews
Ensure compliance with federal, state, and CMS regulations related to PACE and health plan operations
Maintain documentation and audit readiness across enrollment and eligibility processes
Support government relations and policy tracking related to eligibility and enrollment requirements
Perform operational and financial analysis related to enrollment, eligibility, and program performance
Use data analysis to proactively identify risks in enrollment accuracy and revenue performance
Develop and maintain reports and dashboards tracking enrollment trends, eligibility status and discrepancies, revenue risks and impacts, and operational KPIs
Provide insights and recommendations to leadership to support strategic planning and performance improvement
Identify inefficiencies and operational risks within enrollment and eligibility workflows
Recommend and implement process improvements to enhance accuracy, efficiency, and participant experience
Communicate process updates and policy changes across programs
Support system implementations, workflow enhancements, and expansion into new markets or sites
Partner with Participant Benefit Specialists and site teams to promote consistent and compliant enrollment practices
Perform other duties as assigned to support departmental and organizational goals