We are Alivi!

We believe that the measure of our success is not solely based on the bottom line, but on our contributions toward the improvement of the quality of life of our communities. Our strategy is simple, we listen to the needs of our market and develop the most innovative services across the healthcare, technology, and support services industries to address and alleviate those needs. The results? Increased efficiency and scalability, lowered costs, improved workflows, improved member satisfaction, the list goes on. We are a company of thinkers, movers, and shakers, but above all, of people who care. We are Alivi.


Great Atmosphere
Great Employee Benefits
401k Match
Paid Time Off
Great Challenges
Professional Development
Opportunities for Advancement

Current Job Openings

Quality Assurance Analyst

Doral, FL
Job Type

SUMMARY: Responsible for ensuring software systems meet the established standards of quality including reliability, usability and performance. Analyze functional business requirements for completeness. Create test cases and test plans, execute test scripts, and identify variations from expected results. Evaluate and follow up on responses from team on reported issues. Manage and lead multiple projects simultaneously, prioritize and deliver them on time with a pre-defined level of quality.


· Draft and follow quality assurance policies and procedures

· Interpret and implement quality assurance standards

· Evaluate adequacy of quality assurance standards

· Devise and follow sampling procedures and directions for recording and reporting defects

· Writing of clear and comprehensive test cases including test steps for each case executed

· plan, conduct and monitor testing of new code to ensure system functionality based specifications

· Document defects in detail with steps to reproduce following defect reporting guidelines

· Investigate customer reported defects and non-conformance issues

· Collect and compile statistical quality data

· Analyze data to identify areas for improvement in the quality system

· Develop, recommend and monitor corrective and preventive actions

· Prepare reports to communicate outcomes of quality activities

· Identify training needs and organize training interventions to meet quality standards

· Evaluate User Acceptance Test findings and implement appropriate corrective actions

· Monitor risk management activities

· Assure ongoing compliance with quality standards

· Identify areas where test automation can be implemented to streamline the testing cycle


· Angular knowledge and end to end automated testing

· AWS knowledge

· SOAP & JSON knowledge

· Automated Testing is a plus

· Agile experience

· Microsoft SQL Server experience

· Mobile application testing experience is a plus

· Possesses an understanding of IT systems and capabilities

· Excellent interpersonal skills with the ability to effectively interact with all levels of the business.

· Solid knowledge of the SDLC and Web technologies

· Excellent written skills in English

Applications Support Analyst

Doral, FL
Job Type

The Application Support Analyst owns the configuration andfunctionality of the RAM or like-applicable software product or suite ofproducts. Must be familiar with all parts and functionalities of the softwaresystem, understand how the software application fits the users requirements,and fulfills Alivi’s vital business needs. The Application Support Analyst willknow and understand the Alivi business lines and functionalities, and must beable to identify and apply functionality improvements or upgrades to thesoftware product.


· As the owner of the application, the configuration andoperation of the software is the primary responsibility, and acts as theprimary point of system issues escalations.

· Functions as the primary point of contact betweenHealthPlan Ops team, PMO, and the software provider to address and resolveconfiguration related problems, upgrades, implementations, etc.

· Facilitate internal user education and trainingto increase proficiency, effectiveness, and efficiency with the softwareproduct suite.

· Defines and documents process and procedures forsoftware product suite for users and compliance.

· Performs reseach, analysis, and problem resolutionrelated to software product suite usage and functionality.

· Regular consultation with operations and managementregarding the system.

· Provides important communication between Alivi and thesoftware vendor in regards to software questions, issues, or business needs.

· Creates and provides trend analysis reports whenrequired, and assits with report requests as needed.

· Interface with leaders and other internaldepartments to align user needs and business requirements.

· Responsible for managing providers and communicatingchanges and upgrades to Alivi users.

· Works on special projects and performs otherduties as assigned

· Possess excellent communication(verbal/written), organizational and interpersonal skills.

· Manage multiple tasks, must be detail oriented,responsive, and demonstrate independent thought and critical thinking.

· Conveys a strong professional image, exhibitinterest and positive attitude toward all assigned work.

· This position description identifies theresponsibilities and tasks typically associated with the performance of theposition. Other relevant essential functions may be required.


· Excellent verbal and written communicationskills

· Familiarity with payor software systems

· Ability to quickly learn a new software product

· Analyze and document business needs related tosoftware functionality

· Familiarity with Microsoft Office products

· Familiarity with SQL queries

· Familiarity with DB2 databases

· UNIX knowledge

· Strategic, analytical, process oriented and musthave critical thinking skills.

· Excellent written and verbal communicationskills.

· Self-started with ability to work independentlyor in a team environment.

· Ability to manage multiple priorities.

· Excellent problem-solving skills, good follow-upabilities and willingness to be flexible and adaptable to changing priorities.


· 3+ years in healthcare software (preferably payorsoftware).

· Healthcare software implementation orconfiguration experience.

· Experience with Medicare Advantage, ManagedMedicaid, Commercial is a plus.

· Project management experience is a plus


· Bachelors degree in computer science orbusiness/computer information systems or equivalent experience.

Pre-Credentialing Specialist

Lake Worth, FL
Job Type


  • Furnishes workers with clerical supplies.
  • Opens, sorts, and distributes incoming mail, and collects, seals, and stamps outgoing mail.
  • Delivers oral or written messages.
  • Collects and distributes paperwork, such as records or timecards, from one department to another.
  • Marks, tabulates, and files articles and records.
  • Operates office equipment such as envelope-sealing machine, letter opener, record shaver, stamping machine, transcribing machine, photocopying machine, and typewriter.
  • Delivers items to other business establishments.
  • Performs other related duties as assigned by management.


  • High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
  • Strong written, verbal, and interpersonal communications skills including ability to listen attentively and to communicate information clearly and effectively
  • Demonstrated interpersonal, collaborative, and relationship-building skills; ability to interact positively with teammates at various levels across the company and customers
  • Demonstrated ability to work well with cross-functional groups
  • Have a positive attitude and keep a solution-based and customer-focused mindset at all times.
  • Take pride in quality of work and attention to detail.
  • Professional in-person and phone presence and etiquette.

Provider Relations Representative

Lake Worth, FL
Job Type


We are seeking an energetic, innovative and entrepreneurial Provider Relations Representative to join our growing provider operations team in Lake Worth. The Provider Relations Representative provides internal and external support and follow-through to completion of the Provider Relations function. This function includes acting as the network physician liaison, building strategic and collaborative partnerships with network providers. Ensuring a competitive network based on network adequacy reports, health plan or client needs. Helping facilitate the business development team’s ability to strategically penetrate new provider networks, counties, regions, and areas of opportunities. Conducts research, offering problem resolution on a variety of provider or member issues that may arise. Coordinates activities with other internal departments to provide optimal customer service to network providers and internal customers.


· Function as the single point-of-contact for all service issues as needed by providers.

· Facilitate provider education and training to increase their familiarity and satisfaction with our systems, policies and procedures.

· Assure provider adherence to the Provider Manual.

· Create trend analysis and summaries for decision-making purposes.

· Interface with leaders and other internal departments to align contracting needs and business efforts.

· Set targets and priorities to meet specific network needs.

· Responsible for managing providers in multiple markets, regions, counties, lines of business and provider networks.

· Assists with report requests for network management purposes.

· Performs research and problem resolution on provider related issues including provider complaints, claims reported to have been processed incorrectly, etc.

· Provides assistance in compilation, communication and mailing of general information and educational materials to network providers as required.

· Works on special projects and performs other duties as assigned

· Possess excellent communication(verbal/written), organizational and interpersonal skills.

· Manage multiple tasks, be detail oriented, responsive, and demonstrate independent thought and critical thinking.

· Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.

· Maintain accurate provider data in our system as well as our CRM.

· Travel, as required.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Minimum Entry Level Qualifications

· High school diploma or equivalent.

· Minimum of 3 years’ provider relations experience.

· Experience with Medicare Advantage, Managed Medicaid, Commercial.

· Be a self-starter, ability to work independently and handle ambiguity.

· Strategic, analytical, process oriented and must have critical thinking skills.

· Excellent written and verbal communication skills.

· Strong Customer Service orientation.

· Ability to work independently or in a team environment.

· Ability to manage multiple priorities.

· Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities.

· Intermediate with Microsoft Word, Excel, PowerPoint & Outlook.

Role Desirables

· Experience in customer service, claims processing, claims auditing or provider relations for Provider Networks such as Physical, Occupational, Speech and Message Therapies, Chiropractic, Wound Care, Behavioral Health, Non-Emergency Medical Transportation, etc.

· Proficiency in analyzing Network Adequacy reports.

· Proficiency utilizing Quest Analytics application.

· Experience presenting to a variety of audiences.

· Proficiency in analyzing, understanding and communicating financial trends.

· Project management experience.

Quality Assurance Specialist - Contact Center - Transportation

Doral, FL
Job Type
Salary: $15.00 to $19.00 /hour

The Quality Assurance Specialist or QAS plays an integral part in the Operations for Alivi NEMT Transportation. The incumbent is responsible for ensuring the accuracy of information provided and the quality of service delivered through the evaluation and monitoring of phones calls, coaching and training sessions. The QAS will create and distribute quality metrics to the supported business and make recommendations for service and quality improvements. The QAS will also take point on self-reporting any concerns regarding compliance and FWA irregularities to the appropriate parties


  • Evaluates Contact Center call quality standards by auditing inbound and outbound calls to ensure the highest quality service standards
  • Conducting test calls to Contact Center service representatives
  • Verifies quality assurance results by measuring skills via scripts usage & adherence, product knowledge, service ability, greeting, diction, listening, etiquette, objection handling, ability to effectively articulate protocols, efficiency, and courteous close of call
  • Directs quality initiatives by requiring adherence to quality assurance policies and procedures; developing new models; implementing changes
  • Enforces organizational compliance, FWA and service driven protocols. Document irregularities and takes the necessary action to document, report and initiate the required corrective action
  • Facilitate QA training, coaching and facilitate calibration sessions
  • Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies
  • Contributes to team effort by accomplishing related results as needed
  • Provides feedback to telemarketers by monitoring calls; monitoring feedback for external vendor programs; conducting monthly help sessions


  • Two to five years related experience or equivalent
  • Bilingual – Fluent in English/Spanish, with the ability to read, write and speak
  • Excellent customer service skills
  • Experience in facilitating calibration & training sessions
  • Ability to successfully facilitate a coaching session, regardless of topic in a professional and motivating manner
  • Excellent verbal and written communication skills
  • Proficient on Microsoft Office
  • Ability to understand and follow written and verbal instructions
  • Professional appearance and demeanor
  • Ability to effectively communicate with people at all levels and from various backgrounds
  • Versatility, flexibility, and a willingness to work enthusiastically within a constantly changing environment

EDI Business Analyst

Doral, FL
Job Type


The EDI Business Analyst isresponsible for designing and managing various electronic data flow processesalong with receiving support calls to troubleshoot any EDI customer serviceissues. Acts as the IT support point of contact for electronic communicationvia EDI between outside vendors and clearinghouses. The qualifiedcandidate will participate in system design and quality assuranceactivities. This position requires a mix of technical knowledge,analytical ability, clear written and verbal communication skills, and anunderstanding of system processes and production workflows. A deepunderstanding of HIPAA requirements and X12N EDI Professional andInstitutional (notlimited to 837, 835, and 834) is required. General system troubleshootingprocesses from problem notification through resolution is required. TheEDI Business Analyst handles communications with trading partners for EDItransaction set-up and ongoing maintenance; coordinates between tradingpartners and networks to ensure mapping compliance; develops guidelines,checklists, procedures, and training documentation as required; and activelycommunicates with team members, management, end users, and external partners topromote sound EDI integrations and related system improvements. TheEDI Business Analyst is able to perform all aspects of the position withadditional responsibilities including but not limited to those outlined below.

Primary Responsibilities:

Able to analyze current businessprocesses and create an equivalent electronic process that can help improvebusiness speed and internal costs.

Conducts statistical analysis todetermine data reliability.

Performs daily EDI-related tasks suchas daily claims reports, total count by vendors, and any report discrepancies.

Acts as a Subject Matter Expert andescalation specialist in regard to problems or situations within the EDI team.

Performs troubleshooting with new andexisting trading partners to resolve technical mapping variations or gaps andfirst-level troubleshooting issues in the production environment.

Establishes and maintains clearinghouserelationships.

Works with project managers in relationto new product launch plans.

Works well under pressure andmultitasks in an interrupt-driven environment.

Participates in special projects andperforms additional duties as required.

Assists other team members asnecessary.

Develops and implements systemsprocedures and forms to improve data collection and management.

Responsible for acting in accordancewith and complying with all departmental and company policies in relation to:

  • Compliance Program
  • Risk Management Program
  • Medicare Program
  • Medicaid Program
  • And others

Ensures data and referential integrityby applying established standards.

Generally work is self-directed and notprescribed.

Works with less structured, morecomplex issues.

Serves as a resource to others.


Required Qualifications:

Bachelor's degree or HS diploma/GEDwith 3+ years HIPAA EDI-related business experience

2+ years EDI experience includingx12.5010; Professional and Institutional

2+ years of Intermediate hands onexperience with SQL Server and Process Automation.

Experience with clearinghouses such asEmdeon, Zirmed, and Availity.

Preferred Qualifications:

Experience with HL7 & DICOMTransactions.

REGTAP, Amazon Web Servers, EdgeServer.

Bilingual (English and Spanish)preferred.

CSR Lead (Contact Center, Team Lead)

Doral, FL
Job Type
Salary: $16.00 /hour

SUMMARY:The role of a CSR Lead is critical to the success ofthe Alivi Operations department. The CSR Lead works very closely with ourvalued Health Plan Members, Transportation Providers and ultimately, our CallCenter Staff.The CSR Lead works in tandem with their team of Customer ServiceRepresentatives, coaching, guiding and developing the skills of theirteam. They will: assist in the trainingof their team, prepare them for providing superior service to each member theyinteract with and provide ongoing support of the day to day activities of thecenter. In order to succeed as a CSR Lead, you must be focused on helping yourteam build the necessary skills to deliver world class service to our membersand partners.


  • EnsuringCustomer Service Representatives (CSR) understand and comply with all callcenter objectives, performance standards, and policies.
  • AnswerCSR questions regarding best practices, protocols and escalations
  • Identifyoperational issues and suggest possible improvements
  • Monitorand evaluate CSR performance, provide learning and coaching opportunities, andfacilitate corrective action where necessary
  • Preparereports, analyze data and assist management implement action plans to achievecenter benchmarks
  • Collaboratewith peers within the department and Alivi family to support CSR initiativesand maximize customer satisfaction
  • Availableto work any shift, including night shifts, holidays & weekends


  • Fullybilingual (English/Spanish).
  • Minimumof 2 years’ leadership experience, preferably in a contact center environment
  • Proficiencyin technology, CRM solutions, scheduling software and Microsoft products
  • Mustbe able to adapt to high volume, fast paced environment
  • Utilizeinter-personal skills to interact with employees at all level, vendors, membersand preferred partners
  • Abilityto multitask, prioritize situations and react quickly to changing dynamics
  • Collegedegree preferred

Utilization Management Coordinator

Doral, FL
Job Type


  • Are you passionate about securing quality clinical care for patients?
  • Does analyzing clinical data and advocating for patient need excite you?
  • Do you thrive in a team-oriented environment dedicated to employee success?

This position is responsible for servicing the needs of patients by receiving phone calls from both providers to facilitate the authorization and coordination of referrals utilizing pre-approved screening criteria in compliance with contracted Client's requirements.


  • Receives phone calls and faxed referral requests from providers.
  • Verifies member eligibility and benefits. Inputs all referral requests including ICD-10 and CPT codes into system accurately for electronically generated authorization tracking.
  • Provides referral authorization to external providers per UM Departmental Policy and Procedures and specific contracted Client's process.
  • Requests submission of appropriate medical records according to established criteria for requested service(s).
  • Issues authorization within appropriate timeframe for routine, urgent and emergent requests.
  • Appropriately forwards all referral requests to the next level of review.
  • Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.
  • Coordinates approved services with providers as delegated or required by Plan.
  • Is resource person for PCP to refer to network specialist(s).
  • Compiles monthly departmental statistics.
  • Distributes correspondence and other information to the appropriate parties or departments.
  • Maintains appropriate logs, records, and reports as established by Utilization Department.
  • Documents and communicates areas of concern to supervisor.
  • Identifies providers who are problematic with plan requirements.
  • Adheres to company HIPAA policies and procedures.
  • Ensures integrity of data entry is accurate.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Minimum Qualifications:

  • Strong clinical knowledge, prior patient care or related work experience in the outpatient rehabilitation field required.
  • Knowledge/experience in Medicare/Medicaid and HEDIS criteria is highly desirable
  • Demonstrate excellent organizational skills.
  • Strong computer skills and knowledge of MS Office products, including skills in MS Excel required. Ability to quickly navigate between platforms necessary.
  • Strong written and verbal communication skills are a must have.
  • English / Spanish


  • Healthcare experience in a Health Care Management, HMO, MCO, environment is a must
  • Two years of UM healthcare management, and/or training; or equivalent combination of education and experience.
  • Experience analyzing utilization and/or claim data using InterQual, Milliman or other clinical utilization tools


  • High school diploma or general education degree (GED)
  • Bachelor’s (Preferred)

Talent Acquisition Specialist

Doral, FL
Job Type

SUMMARY: The Talent Acquisition Specialist will deliver full life-cycle recruiting. To be successful in this role, you should be able to take ownership, develop long-term recruiting strategies, and nurture trusting relationships with potential hires. Ultimately, this position will create a strong talent pipelines for current and future hiring needs.


  • Take ownership of recruiting and have ability to make decisions that will improve the overall recruiting experience for those seeking new positions and the hiring managers
  • Pre-screens, interviews, assesses, and hires top-quality candidates.
  • Coordinates with HR manager to determine best recruiting process for open position(s).
  • Extends verbal and written contingent job offers.
  • Coordinates and administer background checks for new hires.
  • Completes bi-weekly report on recruitment activity and any other applicable reports.
  • Conducts new hire orientations and follow up interviews.
  • Conducts exit interviews with terminating employees, if needed.
  • Sources candidates through cold calling, search engines, referrals, networking, career fairs, and other avenues.
  • Generates and maintains internal and external job postings; determines effective advertising mediums; places appropriate advertisements.
  • Conducts reference checks and sends rejection letters.
  • Makes recommendations regarding recruitment programs, budgets, and collateral to attract applicants and to fill specific job openings.
  • Researches, analyzes, and prepares recruiting statistics/measurements.
  • With the assistance of the hiring managers, create job description for open positions if needed.
  • Schedules and attends job fairs.
  • Performs other HR related duties as needed.


  • Bachelor’s degree (B.A.) in Human Resources or equivalent experience
  • Two to four years related experience or equivalent
  • Bilingual - English and Spanish
  • Experience in recruiting, staffing and HR regulations
  • Commitment to excellence and high standards
  • Excellent written and oral communication skills
  • Excellent presentation skills
  • Ability to work with all levels of management
  • Strong organizational, problem-solving, and analytical skills
  • Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm
  • Proficient on Microsoft suite.
  • Proven ability to handle multiple projects and meet deadlines
  • Strong interpersonal skills.
  • Ability to deal effectively with a diversity of individuals at all organizational levels.
  • Good judgement with the ability to make timely and sound decisions
  • Creative, flexible, and innovative team player
  • Demonstrated ability to make successful presentations to individuals and/or groups at all levels of an organization
  • Professional appearance and demeanor

Medical Claims Examiner

Doral, FL
Job Type
Salary: $20.00 /hour


We are seeking energetic, innovative and entrepreneurial Medical Claims Examiner to join our growing team in Doral, Florida. This position is intended to provide billing and claims management support to Alivi Specialty Networks and Business Process Outsourcing (BPO) Services. The Medical Claims Examiner will ensure all claims received comply with all health plan, regulatory, contractual, compliance, and Alivi billing guidelines and processes. The Medical Claims Examiner is responsible for the following:


  • Responsible for accurate and timely adjudication of professional claims according to state and federal regulations
  • Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately
  • Demonstrate skills in problem solving, benefit plan, and provider contract Interpretation.
  • Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-10 Codes, under the correct provider contract and member benefits.
  • Helps with Provider Claims Disputes Resolution:
  • Research provider disputes to ensure appropriate resolutions.
  • Works Directly with Clinical Review Board and Network Operations Team to resolve complex issues or disputes
  • Adjudicate claims that have been over turned by the Clinical Review Board or Network Operations Team.
  • Responds to provider disputes in a timely and accurate manner
  • Generates written correspondence to members, providers, and regulatory agencies
  • Responds and assists other departments with complex issues for resolution or affirmation of previously processed claims and existing guidelines.
  • Determine and process overpayments (provider refunds) and reimbursement requests according to specific state and/or federal guidelines or as agreed to in provider contract.
  • Determine and process underpayments (internal errors) and provider reimbursement requests, which may involve the use of spreadsheet research and correspondence.
  • Maintain the department’s claim edit rules and processing claims according to client specific verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing.
  • Identifies trends in claims flows and suggests process improvements.
  • Assist in preparation with Claims Audits

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Minimum Entry Level Qualifications

  • High School diploma or equivalent
  • Minimum 3 years work experience in claims operations environment in the healthcare insurance processing Medicare
  • Hands-on working experience processing medical claims in insurance industry.
  • Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees)
  • Be a self-starter, ability to work independently and in a team environment
  • Strategic, analytical, process oriented and must have critical thinking skills
  • Excellent written and verbal communication skills
  • Ability to manage multiple priorities
  • Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities
  • Works well under pressure
  • Proficient with Excel, PowerPoint, Word & Outlook
  • Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes and Revenue Codes
  • Knowledge of Correct Coding (CCI) Edits
  • Experience in gathering all necessary documentation in preparation of Delegation Audits
  • Detailed knowledge of electronic billing processes universal billing forms

Role Desirables

  • Knowledge of CMS/ACHA Regulations
  • Previous Experience using Health Suite
  • Certified Professional Coder (CPC)

Customer Service Representative - CSR - Contact Center (DORAL)

Doral, FL
Job Type
Salary: $13.00 /hour

SUMMARY: Provides courteous and professional service to health plan partners and the members we serve; strives to ensure that all interaction with customers results in a positive image of the company. Helps deal with and resolve any complaints and answer any questions.


  • Provides timely resolution of customer complaints, concerns, and inquiries
  • Builds effective relationships and trust with customers and potential customers by listening to their needs
  • Responds professionally to all customer requests
  • Supports marketing campaigns and product launches
  • Prepares reports and correspondence as needed
  • Performs other related duties as assigned by management
  • Works with Compliance to respond to ember concerns/issues


  • One to two years related experience or equivalent
  • Bilingual (English/Spanish)
  • Excellent customer service skills
  • Excellent verbal and written communication skills
  • Proficient on Microsoft Office
  • Ability to understand and follow written and verbal instructions
  • Professional appearance and demeanor
  • Ability to effectively communicate with people at all levels and from various backgrounds
  • Versatility, flexibility, and a willingness to work enthusiastically within a constantly changing environment

FULL-TIME (40 hours per week)

Multiple positions to fill as part of our EXPANSION!

Flexible schedules

Wage: $13.00 per hour


Enrollment Coordinator

Doral, FL
Job Type

SUMMARY: This position is responsible for coordination and maintenance of member enrollment into Managed Care Health Plans; maintenance of transfers between plans, counties and primary care physicians; enrollment, disenrollment and cancellation transactions, eligibility verification, member Medicaid, LIS, Hospice and other status updates and ensuring member assignment to a participating Primary Care Physician.


  • Determines and verifies Health Plan status (eligibility) for new and established patients/members. (ei. BEQ or via X12 vendor)
  • Ensures load and processing of monthly or daily enrollment transactions (ei. TRRs MMRs)
  • Researches and reconciles member enrollment data submissions and changes and corrects errors and rejections received on the daily/monthly reports.
  • Reports monthly data on Managed Care enrollments and dis-enrollments as well as work with Reporting team for Adhoc reporting to integrated departments and clients
  • Maintains New Patient Database including any information available from enrollment files to facilitate coordination of care.
  • Handles inquiries and requests to and from patients, customer care, sales agents, health plans, and providers regarding enrollment issues, in a timely and effective manner, and logs information on all interactions timely.
  • Initiates long term solutions when an enrollment issue arises along with appropriate changes to standard operating procedures.
  • Communicates issues/concerns/solutions when necessary to the appropriate leadership for constant process improvement
  • Attends trainings and seminars regarding Managed Care plans accepted and changing regulations in the industry related to sales and enrollment activities
  • Performs other related duties as assigned by management.


  • This job has no supervisory responsibilities.


  • Associate's Degree (AA) or equivalent from a two-year college or technical school, or six months to one year related experience and/or training, or equivalent combination of education and experience.
  • Computer skills required: Microsoft Office Suite
  • Other skills required:
  • Experience in Managed Care Enrollment, Medical Front/Back Office and/or Financial Screening preferred.
  • Ability to work well with others in a professional team oriented environment.
  • Excellent interpersonal and communication skills, and ability to converse comfortably with business, community, and education leaders at all levels.
  • Focus on details and accuracy a must
  • Prioritize activities in a multi-tasking environment.
  • Operate with a sense of urgency and accountability.
  • Meet deadlines, ability to work overtime, reliable attendance
  • Seek assistance when confronting obstacles to achievement of goals.
  • Optimal Candidate will have strong knowledge of Medicare Advantage enrollment life cycle

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