This position is responsible for the overall management of enrollment and billing operations across all Government Programs, including Medicare Advantage, Medicare Supplement, CHIP, and ACA products. In addition, the role oversees Medicare Advantage appeals and grievances operations to ensure regulatory compliance, operational effectiveness, and consistent member experience. The manager provides leadership, strategic direction, and cross functional coordination to support accurate enrollment and billing, compliant appeals resolution, and audit readiness.

• Oversees enrollment and billing operations across Medicare Advantage, Medicare Supplement, CHIP, and ACA products, ensuring accurate eligibility, premium billing, member maintenance, and ongoing operational performance.
• Leads Medicare Advantage appeals and grievances, ensuring timely, compliant resolution of member and provider appeals and grievances in accordance with CMS requirements.
• Ensures compliance with federal and state regulations, including CMS and applicable program requirements, through effective oversight of policies, procedures, controls, and regulatory reporting.
• Directs reconciliation, quality, and performance monitoring activities related to enrollment, billing, and Medicare Advantage appeals, identifying trends, risks, and opportunities for improvement.
• Leads audit readiness and regulatory support efforts, including responses to CMS audits, compliance reviews, and internal oversight activities related to enrollment, billing, and Medicare Advantage appeals and grievances.
• Partners cross‑functionally with Compliance, Claims, Customer Service, Sales, Product, Finance, IT, and other stakeholders to resolve complex operational issues and ensure enterprise alignment.
• Drives process improvement initiatives to enhance accuracy, efficiency, member experience, and regulatory outcomes across all assigned functions.

Skills

• Strong leadership and operational management skills
• Ability to interpret and apply complex regulatory and program requirements
• Effective written and verbal communication skills
• Analytical, decision‑making, and problem‑solving capabilities
• Ability to manage multiple priorities across diverse product lines

Knowledge

• Knowledge of enrollment and billing operations across Medicare and Individual market products
• In‑depth understanding of Medicare Advantage appeals and grievance regulations and processes
• Familiarity with CMS compliance, audit, and oversight expectations
• Understanding of managed care operational workflows and cross‑functional dependencies

Experience

• 5 years’ experience in one or more of the following; enrollment, billing, reconciliation.
• 1 year of staff, team lead or project lead experience.
• Experience managing health insurance enrollment and billing operations
• Experience overseeing Medicare Advantage Appeals and Grievances or related regulatory functions
• Experience supporting compliance activities, audits, and operational improvement initiatives

Education and Certifications

Bachelor’s degree in business, Health Care Administration, or a related field, or equivalent combination of education and experience

Physical Demands

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee may occasionally lift and/or move up to 5 pounds.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.