Eligibility and Enrollment SME

Our client is looking for a skilled Eligibility and Enrollment Subject Matter Expert (SME) to join their team on a contract basis in Nashville, Tennessee (project is fully remote). In this role, you will play a pivotal part in assessing and improving Medicaid enrollment and eligibility operations, ensuring compliance with regulations and optimizing processes. This is an exciting opportunity to collaborate with cross-functional teams and contribute to the development of policies and best practices within the healthcare domain. This is not a Business Analyst role. It is more of a Director-level operations expertise role.

Responsibilities:

• Conduct detailed evaluations of Medicaid enrollment and eligibility operations, including workflows, staffing, and system configurations.

• Identify inefficiencies, compliance risks, and process gaps within the enrollment lifecycle and recommend actionable improvements.

• Analyze performance metrics to ensure accuracy, compliance, and timeliness in eligibility and enrollment processes.

• Review and assess the configuration of eligibility and enrollment modules within the designated system and suggest enhancements.

• Collaborate with IT and business teams to implement system improvements and refine operational processes.

• Provide expert guidance on Medicaid regulations and their impact on eligibility and enrollment workflows.

• Assist in creating and updating policies, procedures, training materials, and job aids for enrollment teams.

• Support compliance reviews, audits, and reporting requirements to ensure regulatory adherence.

• Share best practices and facilitate knowledge transfer across internal teams to promote continuous improvement.

• At least 5 years of experience in Medicaid enrollment and eligibility (mandatory) processes, preferably within a health plan environment.

• Comprehensive understanding of the Medicaid enrollment lifecycle, including eligibility verification, member enrollment, reconciliation, and reporting.

• Strong knowledge of state Medicaid regulations and federal guidelines impacting eligibility and enrollment.

• Practical experience with the designated system, specifically in eligibility and enrollment modules.

• Familiarity with Agile Scrum methodologies and budget management processes.

• Expertise in compliance, patient eligibility, and health care audits related to Medicaid and Medicare.

• Proficient communication skills for collaborating with cross-functional teams and stakeholders.

• Knowledge of tools such as TriZetto QNXT (mandatory) and experience with open, provider, and annual enrollment processes.

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All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

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