As the Director of Enrollment Management, you will spearhead the planning, development, and implementation of all eligibility and enrollment processes across the organization. In this strategic leadership role, you will directly influence access to essential health services by ensuring the smooth administration of eligibility functions and compliance with state, federal, and payer-specific regulations. You will work cross-functionally with departments to drive operational efficiency and optimize enrollment systems, with a particular focus on behavioral health services and physical healthcare.
Responsibilities:
Manages eligibility, benefits, and coverage determination strategies across multiple states (AZ, UT, DC, OK). Develop strategic initiatives to address state-by-state variations in benefits and payer requirements.
Knowledge of Medicare, Medicaid, Tricare, commercial insurance, and federal funding mechanisms to manage payer relations and ensure compliance with payer contracts. Recommend process improvements for managing discrepancies across payers.
Use data analytics tools (Power BI, Excel) to identify trends in population data, discrepancies in coverage, and opportunities for improved payer relations and business growth.
Supervise a team of enrollment specialists, guiding them in managing enrollment, eligibility, and benefit processes, including resolving issues with payers and tracking enrollment trends.
Ensure daily compliance reporting for individuals lacking appropriate coverage. Work closely with inpatient and outpatient leadership, claims, IT, and payers to ensure benefits and eligibility are managed in line with regulatory standards (CFR, AAC).
Develop and oversee internal audits and controls to minimize discrepancies, ensuring payers are updated on changes, and maintaining proper enrollment processes.
Collaborate with departments such as Utilization Review (UR), Billing, Contracting, and IT to streamline communication and improve cross-functional operations.
Qualifications:
Bachelor's degree in behavioral health, healthcare administration, or a related field (Master's degree preferred).
A minimum of 3 years of behavioral health experience, particularly in eligibility verification, benefit management, and enrollment.
A minimum of 5 years of progressive management experience, ideally within the behavioral health industry.
In-depth knowledge of Medicaid, commercial insurance, and public healthcare systems.
Expertise in navigating complex regulations, including CPT, HCPC, and Revenue Codes.
Ability to access and interpret benefits for various healthcare funding streams (e.g., Medicaid, SUBG, MHBG, SOR).