Director; Enrollment

Overview The Director of Enrollment is responsible for operational outcomes of the enrollment and billing teams for assigned lines of business (e.g. Medicare, Medicaid, Commercial). Incumbent will act as subject matter expert for the Enrollment and Billing functions of the Operations organization. The incumbent will facilitate the development of enrollment operations on new lines of business and will ensure successful implementations.

Technical Profile Core Enrollment & Billing Expertise

Deep 834 fluency (not just awareness)

Inbound/outbound file structures, reconciliation, error handling, and retroactivity

Experience with trading partners, clearinghouses, and CMS/state interfaces

Strong understanding of:

Eligibility life cycle (prospective → active → retro → term)

Premium billing (direct bill, group, subsidy interactions)

Coordination with claims (impact of eligibility errors → downstream rework)

Regulatory & Line of Business Expertise

Hands-on experience with at least one:

Medicare DSNP

Medicaid (state-specific nuances)

Commercial (ASO + fully insured)

Working knowledge of:

CMS enrollment guidance, MARx, TRR processing (for Medicare)

State Medicaid eligibility feeds and reconciliation processes

Ability to translate regulation to operations to system configuration

Platform & Systems Orientation

Experience with core admin platforms (examples to probe for depth, not just name-dropping):

Facets,

QNXT , HealthRules, or equivalent

Demonstrated ownership of:

Configuration decisions

Eligibility error queues

Vendor integrations (ID cards, print/mail, etc.)

Operational Analytics & Controls

Strong orientation toward

metrics and controls , not just throughput:

Enrollment accuracy rate

Retroactivity volume

834 reject rates / auto-adjudication rates

Billing variance / reconciliation accuracy

Experience building:

Daily/weekly operational dashboards

Audit controls

Implementation & Transformation Experience

Proven track record in:

New line of business launches

System migrations or platform conversions

Large-scale membership growth or M&A integration

Knows how to stand up:

Parallel testing

File validation frameworks

Go-live stabilization models

Leadership Profile: What to Screen For Operational Leadership (Run)

Has led teams that manage

high-volume, high-accuracy transactional work

Instills discipline around:

SLAs

Quality assurance

First-time-right processing

Strategic Leadership (Change)

Can articulate how enrollment evolves from:

Transactional processing to

proactive eligibility management

Experience reducing:

Call volume driven by eligibility issues

Claims rework driven by enrollment defects

Brings a continuous improvement mindset (Lean, Six Sigma, or equivalent rigor)

Cross-Functional Influence

Proven ability to partner with:

IT (especially around 834s, EDI, platform configs)

Claims (eligibility defect leakage)

Customer service (call drivers tied to enrollment errors)

Can translate operational issues into

financial and member impact language

Vendor & Stakeholder Management

Experience holding vendors accountable:

ID card production SLAs

Print/mail timelines

Clearinghouse performance

Strong governance discipline (QBRs, SLAs, penalties, etc.)

Talent & Culture

Builds teams that:

Understand why accuracy matters (not just processing speed)

Are resilient during peak cycles (AEP, Medicaid redeterminations)

Experience leading through:

High-pressure cycles

Regulatory change

Ambiguity during implementations

Bachelor's degree required.

Previous customer service and management experience required.

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