Director; Enrollment
Sentara Health Plans, Virginia Beach, VA, United States
* Inbound/outbound file structures, reconciliation, error handling, and retroactivity* Experience with trading partners, clearinghouses, and CMS/state interfaces* 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* 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.)* 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* 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)* 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*** Experience holding vendors accountable:
+ ID card production SLAs
+ Print/mail timelines
+ Clearinghouse performance* Strong governance discipline (QBRs, SLAs, penalties, etc.)* 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**Benefits: Caring For Your Family and Your Career****•** Medical, Dental, Vision plans• Adoption, Fertility and Surrogacy Reimbursement up to $10,000• Paid Time Off and Sick Leave• Paid Parental & Family Caregiver Leave• Emergency Backup Care• Long-Term, Short-Term Disability, and Critical Illness plans• Life Insurance• 401k/403B with Employer Match• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education• Student Debt Pay Down – $10,000• Reimbursement for certifications and free access to complete CEUs and professional development•Pet Insurance
•Legal Resources Plan
•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met. #J-18808-Ljbffr
+ **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* 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.)* 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* 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)* 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*** Experience holding vendors accountable:
+ ID card production SLAs
+ Print/mail timelines
+ Clearinghouse performance* Strong governance discipline (QBRs, SLAs, penalties, etc.)* 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**Benefits: Caring For Your Family and Your Career****•** Medical, Dental, Vision plans• Adoption, Fertility and Surrogacy Reimbursement up to $10,000• Paid Time Off and Sick Leave• Paid Parental & Family Caregiver Leave• Emergency Backup Care• Long-Term, Short-Term Disability, and Critical Illness plans• Life Insurance• 401k/403B with Employer Match• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education• Student Debt Pay Down – $10,000• Reimbursement for certifications and free access to complete CEUs and professional development•Pet Insurance
•Legal Resources Plan
•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met. #J-18808-Ljbffr