About The Role The Enrollment & Employer Services II role is a member-facing, bilingual position responsible for resolving more complex eligibility and employer reporting issues. As a Level II role, it handles escalated tasks, supports employer training, and manages the day-to-day functions of enrollment and eligibility processing. This includes ensuring that participants are accurately enrolled in the correct health plans, supporting the Eligibility Call Center, and managing daily communication with participants. The role also coordinates with internal departments to ensure data accuracy and contributes to audits, reporting, and process improvement initiatives.
Primary Responsibilities
Address complex enrollment and eligibility scenarios, including escalated QLEs, urgent enrollments, COBRA corrections, and retiree transitions.
Review, verify, and validate dependent documentation for escalated or sensitive cases.
Investigate and resolve discrepancies in employer-submitted hours, contribution files, and member eligibility records.
Coordinate resolution of complex employer reporting cases, including those involving multiple employer files or home employer changes.
Reconcile reported hours and contributions against collective bargaining agreements and fund rules; identify and address discrepancies.
Follow up with employers on delinquent hours and late contribution payments; prepare supporting documentation such as hour receipt reports, aging reports, and late notices.
Process retroactive, adjusted, vacation, or converted work hours (e.g., shifts, days, weeks to hours) to ensure accurate eligibility outcomes.
Respond to complex inquiries from employers, HR representatives, and internal departments regarding file submissions, contribution issues, and eligibility impacts.
Support onboarding of new employer groups and conduct walkthroughs of portal usage and file submission protocols.
Facilitate and lead employer training webinars or sessions to improve file accuracy and understanding of plan rules.
Collaborate with internal departments (Finance, Customer Service, Claims, IT) to resolve cross-functional data or process issues.
Generate and review audit and aging reports to support internal controls and data reconciliation.
Participate in system testing and recommend workflow or reporting improvements.
Maintain compliance with HIPAA, internal data privacy protocols, and plan rules in all recordkeeping and communications.
Escalate complex or unclear eligibility issues or employer data discrepancies to the Team Lead or Management.
Essential Qualifications
Ability to work alternate schedules/hours based on the business’s needs.
Bachelor’s Degree preferred or High School diploma / GED (or higher) OR 10+ years of equivalent working experience
2+ years of experience in an office setting environment using the telephone and computer as the primary instruments to perform job duties
Knowledge of managed care, labor, and commercial carrier enrollment and eligibility procedures, including hourly based eligibility and waiting periods.
Prior experience with premium billing and reconciliation, knowledge of 834 eligibility files, and transaction sets is a plus.
Fluent in COBRA, FMLA, QLE’s and other eligibility-related transactions a plus
Moderate proficiency with Windows PC applications, which includes the ability to learn new and complex computer system applications
Ability to multitask, which includes the ability to understand multiple products and multiple levels of benefits within each product
