WHAT DOES AN ENROLLMENT SPECIALIST DO?

Updated: Jun 11, 2025 - The Enrollment Specialist processes enrollment eligibility data, generates member materials, and coordinates identification card issuance. This role involves quality assurance, performing peer audits, providing coaching, and resolving escalated eligibility inquiries with a focus on maintaining 98% accuracy. The specialist also has improvement initiatives including identifying knowledge gaps, enhancing processes, and addressing patterns in member issues through root cause analysis and collaboration with leadership.

A Review of Professional Skills and Functions for Enrollment Specialist

1. Enrollment Specialist Accountabilities

  • Process Management: Process work items according to appropriate regulatory guidelines.
  • Data Interpretation: Review files and interpret the data to enter members into eligibility systems.
  • Exception Handling: Complete daily change file pre-processor exceptions and monthly full file pre-processor exceptions.
  • Research and Troubleshooting: Research member eligibility and take appropriate actions to resolve issues across all eligibility systems.
  • Provider Coordination: Process mass Primary Care Physician (PCP) changes with Provider Operations.
  • Eligibility Support: Research, review, and interpret eligibility data to respond to eligibility inquiries from contracted vendors.
  • System Navigation: Access state and federal government systems to review and confirm eligibility status.
  • Application Processing: Process paper applications received for all applicable lines of business.
  • Customer Support: Inbound phone coverage to answer inquiries from both internal and external customers.
  • Training Compliance: Complete all required corporate training within stated timelines satisfactorily.

2. Medicaid Enrollment Specialist Job Summary

  • Enrollment and Credentialing: Responsible for the enrollment and credentialing processes for Medicaid Enrollment across the U.S.
  • Website Monitoring: Monitors state Medicaid websites where we are enrolled to ensure websites are reviewed and relevant changes are documented on a routine basis.
  • Policy Updates: Updates ACH on Medical policy changes that impact business.
  • Reimbursement Management: Updates ACH on any reimbursement changes.
  • Revenue Cycle Coordination: Works closely with Revenue Cycle Management and interprets reimbursement criteria for payment.
  • Regulatory Compliance: Ensure ACH meets state Medicaid-mandated requirements to maintain licensure.
  • Collaboration: Works closely with Regulatory and Audit to collaborate on statewide requirements.
  • Data Management: Maintains up-to-date data for each state Medicaid program to ensure timely renewal of licenses and certifications.
  • Credentialing Tracking: Record and track credentialing statistics and document the preparation of contract logs on a routine basis.
  • Credentialing Process: Responsible for the processing of credentialing requirements, maintaining effective credentialing logs and relevant controls, and assisting in the optimization of contractual outcomes.
  • State Enrollment Compliance: Ensures that new state enrollments align with pre-defined business requirements.
  • Credentialing Timeliness: Ensures timely completion of credentialing and re-credentialing process as defined by each state Medicaid program.

3. Enrollment Specialist Responsibilities

  • Recruitment and Screening: Call to recruit and pre-screen subjects to determine if they pre-qualify to participate in one of the research studies.
  • Patient Communication: Talk to patients in the clinic about studies, verify qualifications, and discuss studies with parents of pediatric subjects.
  • Appointment Management: Call subjects to confirm appointments, follow up on no-show appointments, and reschedule appointments when necessary.
  • Advertising: Post ads where necessary to promote enrolling studies.
  • Database Management: Enter all qualifying and potential patients into the company database.
  • Call Handling: Handle high volume of incoming and outgoing calls.
  • File Review and Updates: Review member files providing updates and information per established program policies.
  • Data Entry: Performs data entry and matches documents to appropriate member accounts to ensure up-to-date and accurate information is placed on file.
  • Eligibility Updates: Receive forms/calls from the Division of Family and Children Services (DFCS) to update member eligibility information.
  • Eligibility Status Review: Review member files to provide the status of eligibility.
  • Customer Service: Answers incoming calls and responds to basic customer questions and/or transfers calls to the appropriate personnel/department.

4. Enrollment Specialist Overview

  • Relationship Management: Maintain meaningful relationships with new and existing customers.
  • Client Support: Respond to inquiries, assist in enrollment processes, and resolve potential client issues.
  • Sales: Create, present, and sell company products and services to drive enrollment numbers.
  • Financial Reporting: Prepare and maintain account statements and financial reports for customers.
  • Market Research: Stay updated with the market by conducting research and building knowledge.
  • Competitive Analysis: Study industry trends and competitive market information to stay ahead of the competition.
  • IT Collaboration: Partner with IT to diagnose, perform user acceptance tests (UAT), and approve code fixes into production.
  • Process Improvement: Enhance organizational efficiency by participating in cross-functional projects related to member enrollment manual processing.
  • Compliance Management: Ensure regulatory and legal compliance (HIPAA) within the department.
  • Service Promotion: Promote and support service guarantees (e.g. GOSE).
  • Certification Administration: Administer the monthly and annual overage-dependent (student) certifications, identify automation opportunities, and eliminate the mailing of letters.
  • Business Continuity: Maintain business continuity and disaster recovery processes and procedures, using tools such as Evergreen.

5. Enrollment Specialist Role Purpose

  • Eligibility Data Processing: Processing enrollment eligibility data for all product lines.
  • Eligibility Guidelines Administration: Understanding and administering eligibility/enrollment guidelines, including waiting periods, continuation guidelines, maximum age policies, including the student certification process for specified groups.
  • Enrollment Materials Generation: Generating all required member enrollment materials.
  • Card Coordination: Coordinating the processing of member identification cards.
  • Reporting and Analysis: Reporting status of Service Level Agreements to Enrollment Leadership and providing a recommended path forward.
  • Subject Matter Expertise: Acting as a Subject Matter Expert, Enrollment Specialist II will maintain 98% personal accuracy.
  • Quality Auditing and Coaching: Performing peer quality audits and providing subject matter coaching and feedback aimed at improving department quality.
  • Eligibility Troubleshooting: Troubleshooting and resolving member eligibility inquiries in real time.
  • Knowledge Gap Identification: Identifying department gaps in knowledge.
  • Escalation Resolution: Fielding and resolving escalated and time-sensitive issues.
  • Audit Support: Assisting with audit preparation and document gathering.
  • Department Representation: Representing the Enrollment department's needs in projects or meetings that impact member eligibility.
  • Process Improvement: Assisting in the development of documentation of processes and procedures into functional process improvements to enhance the overall level of service to customers and partners.
  • Root Cause Analysis: Using the Improvement model, identifying patterns in urgent member issues, conducting root cause analysis, and reporting to the management team.
Relevant Information
What Does An Enrollment Do?