City/State

Work Shift

Overview:

Overview

The Director of Enrollment is responsible for operational outcomes of the enrollment and billing teams for assigned lines of business (e.g. Medicare Medicaid Commercial). Incumbent will act as subject matter expert for the Enrollment and Billing functions of the Operations organization. The incumbent will facilitate the development of enrollment operations on new lines of business and will ensure successful implementations.

Technical Profile:

Core Enrollment & Billing Expertise

• Deep 834 fluency (not just awareness)
  • Inbound/outbound file structures reconciliation error handling and retroactivity
  • Experience with trading partners clearinghouses and CMS/state interfaces
• Strong understanding of:
  • Eligibility life cycle (prospective active retro term)
  • Premium billing (direct bill group subsidy interactions)
  • Coordination with claims (impact of eligibility errors downstream rework)

Regulatory & Line of Business Expertise

• Hands-on experience with at least one:
  • Medicare DSNP
  • Medicaid (state-specific nuances)
  • Commercial (ASO fully insured)
• Working knowledge of:
  • CMS enrollment guidance MARx TRR processing (for Medicare)
  • State Medicaid eligibility feeds and reconciliation processes
• Ability to translate regulation to operations to system configuration

Platform & Systems Orientation

• Experience with core admin platforms (examples to probe for depth not just name-dropping):
  • Facets QNXT HealthRules or equivalent
• Demonstrated ownership of:
  • Configuration decisions
  • Eligibility error queues
  • Vendor integrations (ID cards print/mail etc.)

Operational Analytics & Controls

• Strong orientation toward metrics and controls not just throughput:
  • Enrollment accuracy rate
  • Retroactivity volume
  • 834 reject rates / auto-adjudication rates
  • Billing variance / reconciliation accuracy
• Experience building:
  • Daily/weekly operational dashboards
  • Audit controls

Implementation & Transformation Experience

• Proven track record in:
  • New line of business launches
  • System migrations or platform conversions
  • Large-scale membership growth or M&A integration
• Knows how to stand up:
  • Parallel testing
  • File validation frameworks
  • Go-live stabilization models

2) Leadership Profile: What to Screen For

Operational Leadership (Run)

• Has led teams that manage high-volume high-accuracy transactional work
• Instills discipline around:
  • SLAs
  • Quality assurance
  • First-time-right processing

Strategic Leadership (Change)

• Can articulate how enrollment evolves from:
  • Transactional processing to proactive eligibility management
• Experience reducing:
  • Call volume driven by eligibility issues
  • Claims rework driven by enrollment defects
• Brings a continuous improvement mindset (Lean Six Sigma or equivalent rigor)

Cross-Functional Influence

• Proven ability to partner with:
  • IT (especially around 834s EDI platform configs)
  • Claims (eligibility defect leakage)
  • Customer service (call drivers tied to enrollment errors)
• Can translate operational issues into financial and member impact language

Vendor & Stakeholder Management

• Experience holding vendors accountable:
  • ID card production SLAs
  • Print/mail timelines
  • Clearinghouse performance
• Strong governance discipline (QBRs SLAs penalties etc.)

Talent & Culture

• Builds teams that:
  • Understand why accuracy matters (not just processing speed)
  • Are resilient during peak cycles (AEP Medicaid redeterminations)
• Experience leading through:
  • High-pressure cycles
  • Regulatory change
  • Ambiguity during implementations

Bachelors degree required.

Previous customer service and management experience required.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30000-member workforce. Diversity inclusion and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission to improve health every day this is a tobacco-free environment.

For positions that are available as remote work Sentara Health employs associates in the following states:

Alabama Delaware Florida Georgia Idaho Indiana Kansas Louisiana Maine Maryland Minnesota Nebraska Nevada New Hampshire North Carolina North Dakota Ohio Oklahoma Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Washington West Virginia Wisconsin and Wyoming.