Enrollment Quality Auditor

HealthEdge

. Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates .

Posted 10/5/2026full-timeRemote • United StatesMid-LevelSenior💰 $44,000 - $50,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in health plan enrollment auditing, including Medicaid managed care guidelines and dual-eligible enrollment processes. Proficient in analyzing enrollment transactions and ensuring compliance with CMS and state standards.

Highest-signal resume keywords

Health Plan Enrollment AuditingMedicaid Managed Care GuidelinesDual-Eligible Enrollment CoordinationProficiency in MS SuiteEDI 834 Enrollment Transactions

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Enrollment AuditingEligibility VerificationData AnalysisQuality AssuranceMedicaid RedeterminationsAudit ReportingContractual SLA AnalysisKPI AnalysisEnrollment Processing Timeliness

Soft Skills

Effective CommunicationCollaborationIndependent WorkTeamwork

Tools & Technologies

HealthRules® PayorGuidingCare®MS ExcelMS PowerPointMS Outlook

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

MedicaidMedicareManaged Long-Term Care (MLTC)Enrollment TransactionsAudit FindingsClient Audit Teams

About the role

Key responsibilities & impact

Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates
Follow customer quality processes and tools for audit and rebuttal activities
Review enrollment (834) file transactions and coordinate with state enrollment systems and enrollment brokers
Confirm accuracy of member effective dates, retroactive enrollment/disenrollment, and eligibility segments
Verify timely and accurate Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards
Audit dual-eligible Medicare-Medicaid enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits
Share QA results with associates and coordinate with Team Leads and managers to provide feedback
Compile and report team and individual QA performance to management and associates
Provide input to Training and Team Lead teams for processing instructions and refresher training
Participate in Audit the Auditor programs
Participate in semi-annual or annual auditor calibration activities
Maintain current knowledge of CMS Medicaid managed care guidelines, state Medicaid enrollment requirements, and MLTC enrollment/disenrollment rules
Report audit findings to client audit teams and operational managers

Requirements

What you’ll need

High School Diploma or GED required
3 years health plan enrollment/eligibility auditing operations experience required
Medicaid managed care enrollment auditing experience preferred
Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience strongly preferred
Proficiency in MS Suite, specifically Excel, PowerPoint and Outlook
HealthRules® Payor or GuidingCare® experience preferred
Familiarity with EDI 834 enrollment transactions and eligibility verification systems a plus
Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness
Ability to effectively communicate and collaborate with a remote team
Ability to work independently with limited supervision and collaboratively in a team environment
Candidates may be required to complete a pre-employment criminal background check
Must work across multiple time zones
Ability to meet physical demands including prolonged sitting and/or standing at a computer, and required vision abilities

Benefits

Comp & perks

Remote work environment
Hybrid or remote work environment
May require travel dependent on company needs
Reasonable accommodations for individuals with disabilities
Equal opportunity and workforce diversity commitment