Classicare Enrollment & Eligibility Analyst

GENERAL DESCRIPTION: Responsible for the accurate and timely administration of enrollment, disenrollment, eligibility, and benefit maintenance processes in compliance with federal, state, Center for Medicare and Medicaid Services (CMS), Puerto Rico Health Services Administration (ASES), and organizational requirements. Performs analytical review of enrollment transactions, maintains data integrity across multiple systems, and supports operational areas through research, issue resolution, and process coordination. ESSENTIAL FUNCTIONS: •Receives, reviews, and processes enrollment, disenrollment, cancellation, reinstatement, and coverage change requests within established service level agreements (SLAs) and regulatory timeframes. •Evaluate and analyze enrollment documentation to determine member eligibility, ensure compliance with federal, state, CMS, ASES, and organizational requirements, and establish appropriate effective dates and eligibility periods. •Identifies applications with missing, incomplete, or inconsistent information; initiates the required return processes and coordinates notifications to members and appropriate departments. •Reviews and validates pending enrollment and eligibility reports to ensure timely case resolution and compliance with regulatory and departmental requirements. •Ensures all processed transactions are supported by the appropriate member notifications and correspondence within established regulatory timeframes. •Investigates enrollment and eligibility issues and provides recommendations for resolution to internal stakeholders, leadership, and operational departments. •Conducts research and performs data validation activities to identify, analyze, and correct eligibility, enrollment, and demographic discrepancies. •Responds to inquiries and service requests from internal departments through designated applications, distribution lists, and workflow management systems. •Maintains accurate documentation of actions taken and ensures compliance with audit, quality assurance, and regulatory requirements •Processes PCP assignment and reassignment requests in accordance with established policies, provider network requirements, and company-approved assignment rules. •Reconciles PCP information across multiple organizational systems and databases to ensure accuracy, consistency, and data integrity. •Participates in departmental projects, process improvement initiatives, system testing, and operational readiness activities as assigned. • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. •May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and experience: Bachelor’s Degree. At least six (6) months of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry. OR Education and experience: Associate’s Degree or Sixty to sixty-four (60-64) college credits. At least one (1) year of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry. OR Education and Experience: High School Diploma or Technical Course. At least two (2) years of experience in group and individual enrollment processes, preferably with Medicare Advantage products in the Healthcare Insurance Industry. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: Not required. Other: N/A Languages: Spanish – Intermediate (comprehensive, writing, and verbal) English – Basic (comprehensive, writing, and verbal)