Enrollment Specialist Medicare Advantage (US Healthcare)

Role Overview

The Enrollment Specialist is responsible for reviewing, validating, and processing Medicare Advantage (MA/MA-PD) enrollment and disenrollment requests in accordance with Centers for Medicare & Medicaid Services (CMS) regulations, Medicare Advantage and Part D Enrollment and Disenrollment Guidance, election period requirements, effective-date rules, and health plan policies.

The role requires strong knowledge of Medicare Advantage eligibility, CMS election periods, enrollment and disenrollment processes, beneficiary eligibility research, and the Medicare Advantage Prescription Drug System (MARx). Working closely with Enrollment Operations, Member Services, Sales/Broker Operations, Billing, Claims, Pharmacy, IT, and Compliance, the Enrollment Specialist ensures accurate, timely, and compliant enrollment processing while delivering an exceptional member experience.

This is a compliance-critical role requiring excellent analytical ability, strong MARx research skills, accurate documentation, attention to detail, and a customer-focused mindset.

Key Responsibilities

Medicare Advantage Enrollment Processing

• Review and process Medicare Advantage and MA-PD enrollment, disenrollment, cancellation, plan-change, correction, and reinstatement requests, as applicable.
• Validate enrollment requests for completeness and accuracy, including beneficiary identifiers, demographics, plan/PBP information, request receipt date, election type, and requested effective date.
• Apply CMS Medicare Advantage enrollment and disenrollment requirements, health plan policies, and established operational procedures.
• Determine the appropriate enrollment effective date based on the beneficiary's eligibility, election period, and CMS requirements.
• Identify incomplete, conflicting, duplicate, untimely, or potentially invalid enrollment requests and initiate the appropriate research, outreach, correction, or escalation.
• Ensure enrollment actions and required member notifications are completed within applicable CMS and organizational processing timeframes.

Eligibility & Election Period Validation

• Confirm Medicare Part A and Part B entitlement and other applicable Medicare Advantage eligibility requirements using authorized systems and CMS data.
• Validate plan service-area eligibility and applicable CMS citizenship or lawful-presence requirements.
• Determine and document the appropriate election period, including ICEP, AEP, MA OEP, OEPI, and Special Election Periods (SEPs), as applicable.
• Review supporting documentation or beneficiary attestations required to substantiate Special Election Period eligibility when applicable.
• Escalate complex eligibility, election-period, effective-date, or conflicting enrollment-history issues to Enrollment leadership or Compliance when appropriate.

Member & Enrollment Support

• Handle inbound and outbound contacts related to enrollment status, eligibility, effective dates, disenrollment, and enrollment documentation requirements.
• Clearly explain enrollment processes, CMS requirements, missing-information needs, transaction status, and next steps in member-friendly language.
• Demonstrate empathy, professionalism, and active listening while interacting with members, authorized representatives, caregivers, brokers, providers, and internal teams.
• Resolve enrollment inquiries while maintaining excellent customer service standards and avoiding activities that require insurance sales licensure unless separately authorized.

MARx, Transaction Reconciliation & Enrollment Documentation

• Navigate the CMS Medicare Advantage Prescription Drug System (MARx/MARx UI) within assigned security roles to research beneficiary eligibility and enrollment information.
• Review beneficiary enrollment history, current plan enrollment, Medicare entitlement information, and transaction status to support enrollment investigations.
• Submit or support enrollment and disenrollment transactions in MARx when authorized and in accordance with organizational procedures.
• Review CMS Daily Transaction Reply Report (DTRR) results and Transaction Reply Codes (TRCs) to determine whether enrollment transactions were accepted, rejected, or require additional action.
• Research rejected, failed, or conflicting enrollment transactions, identify the root cause, and complete or coordinate corrective action and resubmission.
• Reconcile internal membership records against CMS/MARx enrollment information and identify discrepancies requiring correction.
• Maintain clear, complete, and accurate case notes documenting beneficiary research, election-period validation, MARx findings, actions taken, and final resolution.
• Prepare and issue CMS-compliant enrollment correspondence, requests for additional information, confirmations, denial notices, or other required communications, as applicable.
• Coordinate complex MARx or CMS transaction issues with Enrollment leadership, IT/EDI support, Compliance, or the MAPD Help Desk, as appropriate.
• Identify and escalate documentation discrepancies, privacy concerns, system-access issues, or potential regulatory non-compliance before finalizing the enrollment action.

Compliance & Quality

• Adhere to CMS Medicare Advantage enrollment and disenrollment requirements, HIPAA requirements, CMS information-security standards, and organizational policies.
• Meet established quality, productivity, accuracy, service-level, and enrollment processing performance metrics.
• Participate in internal quality reviews, calibration sessions, regulatory audits, and CMS audit-readiness activities.
• Support enrollment audit readiness by ensuring case files, election-period evidence, transaction history, member communications, and system documentation are complete and accurate.
• Perform or support quality review of enrollment cases to validate eligibility, election period, effective date, transaction outcome, documentation, and regulatory compliance.
• Confirm all required documentation is present within the enrollment record to support the action taken and the final enrollment status.
• Identify enrollment error trends, recurring TRCs, quality gaps, and opportunities for corrective and preventive action.
• Support continuous quality improvement through feedback, education, root-cause analysis, and process enhancement activities.
• Maintain complete, accurate, secure, and audit-ready documentation supporting all enrollment and disenrollment actions.

Collaboration & Escalation

• Partner with:
• Enrollment Operations
• Member Services
• Sales / Broker Operations
• Billing & Premium Operations
• Claims
• Pharmacy / Part D Operations
• Quality & Compliance
• Participate in cross-functional case discussions involving complex eligibility, enrollment, access-to-care, or member-impact issues.
• Escalate complex MARx, CMS, regulatory, system, or beneficiary-impact issues appropriately.
• Support knowledge sharing, process improvement initiatives, and cross-functional collaboration across Medicare operations.

Required Experience & Qualifications

Must Have

• Bachelor's degree in Healthcare Administration, Business Administration, Life Sciences, Pharmacy, Allied Health, or a related discipline.
• Hands-on working knowledge of the CMS MARx system and Medicare Advantage enrollment transaction workflows.
• Minimum 3–5 years of experience in US Healthcare Operations.
• Minimum 2 years of experience in Medicare Advantage Enrollment, Membership Operations, Eligibility, Medicare Member Services, or related health plan operations.
• Strong understanding of CMS Medicare Advantage eligibility, enrollment, disenrollment, election-period, and effective-date requirements.
• Experience researching CMS enrollment transactions, including DTRR results and Transaction Reply Codes (TRCs), or equivalent enrollment-response workflows.
• Working knowledge of Medicare Part A and Part B entitlement, service-area eligibility, and common Medicare Advantage election periods and SEPs.
• Experience researching enrollment discrepancies, reconciling membership records, and documenting corrective actions.
• Excellent analytical, problem-solving, and decision-making skills.
• Strong verbal and written communication skills with the ability to explain complex enrollment requirements clearly.
• Ability to consistently meet CMS processing requirements, quality expectations, and operational service levels.

Preferred

• Experience supporting Medicare Advantage health plans, MA-PD products, or Managed Care Organizations (MCOs).
• Experience with D-SNP, C-SNP, I-SNP, Medicaid/dual-eligibility, Low-Income Subsidy (LIS), or other special-population enrollment workflows.
• Experience using Facets, HealthEdge/HealthRules, QNXT, Salesforce, or similar enrollment, membership, or health plan administration platforms.
• Exposure to CMS audits, enrollment compliance reviews, CMS transaction files, and Medicare regulatory documentation requirements.
• Experience collaborating with Enrollment, Member Services, Sales/Broker Operations, Billing, Claims, Pharmacy, IT/EDI, and Compliance teams.

Key Competencies

• MARx navigation and beneficiary research
• CMS enrollment transaction review and reconciliation
• DTRR and Transaction Reply Code (TRC) analysis
• Regulatory Documentation & Audit Readiness
• Enrollment Documentation Integrity
• Eligibility & Election Period Validation
• Member-Focused Written & Verbal Communication
• Root Cause Analysis & Quality Improvement
• Enrollment effective-date determination
• Medicare Advantage & CMS regulatory knowledge
• Enrollment & Disenrollment expertise
• Strong analytical and critical thinking skills
• Regulatory compliance mindset
• Attention to detail and data accuracy
• Excellent verbal and written communication
• Empathy and member advocacy
• Collaboration and stakeholder management
• Time management and SLA adherence