Medicare Enrollment Specialist

The Medicare Enrollment Specialist is responsible for accurately completing Medicare enrollments for eligible beneficiaries while ensuring full compliance with CMS regulations and carrier requirements. This role serves as the final quality checkpoint before an application is submitted, verifying all enrollment details, reviewing plan benefits, and ensuring each beneficiary fully understands their coverage and enrollment decision. The Enrollment Specialist works closely with Producing Agents to deliver an exceptional customer experience while maintaining the highest standards of accuracy and compliance.

Essential Duties and Responsibilities

• Review all information provided by the Producing Agent to ensure the enrollment package is complete before beginning the enrollment.
• Conduct the required introduction and recording statement.
• Re-read the Scope of Appointment (SOA) in its entirety.
• Verify the Medicare plan name with the beneficiary.
• Review and verify all physicians, specialists, and prescription medications.
• Confirm the beneficiary understands if any providers are out-of-network.
• Conduct a complete Summary of Benefits (SOB) review.
• Review each prescription drug, including:
  • Applicable formulary tier.
  • Prior authorization requirements.
  • Quantity limits.
  • Step therapy requirements.
  • Any medications not included on the formulary.
• Read the required enrollment and transition statements in full.
• Obtain an affirmative response from the beneficiary acknowledging understanding before proceeding.
• Complete the Medicare enrollment application by asking every application question directly to the beneficiary without pre-filling responses.
• Verify all application information for completeness and accuracy.
• Read all required CMS and carrier disclosures.
• For D-SNP and C-SNP enrollments, complete all required disclosures before initiating the IVR process.
• Obtain the beneficiary's application signature in accordance with carrier requirements.
• Provide the beneficiary with their enrollment confirmation number.
• Provide the beneficiary with the Producing Agent's direct contact information.
• Complete a Health Risk Assessment (HRA) whenever available and applicable.
• If an HRA cannot be completed, document the reason and notify the Producing Agent promptly.
• Ensure all enrollments comply with CMS regulations, carrier guidelines, and company policies.
• Maintain accurate documentation and protect confidential member information in accordance with HIPAA requirements.
• Collaborate with Producing Agents, management, and carrier partners to resolve enrollment issues in a timely manner.
• Perform other duties as assigned.

Qualifications

• Active resident health insurance license in good standing.
• Must be eligible to obtain and maintain appointments with all required Medicare carriers.
• Prior Medicare Advantage, Prescription Drug Plan (PDP), Medicare Supplement, or health insurance enrollment experience preferred.
• Working knowledge of CMS Medicare regulations and compliance requirements preferred.
• Strong attention to detail and commitment to accuracy.
• Excellent verbal communication and customer service skills.
• Ability to explain complex benefit information clearly and professionally.
• Strong organizational and time management skills.
• Ability to work in a fast-paced, performance-driven environment.
• Knowledge, Skills, and Abilities
• Thorough understanding of Medicare enrollment processes and compliance requirements.
• Ability to identify discrepancies and ensure complete, accurate applications.
• Strong listening skills and ability to build rapport with beneficiaries.
• Ability to manage multiple enrollments while maintaining quality standards.
• Proficiency with CRM systems, enrollment platforms, and Microsoft Office applications.
• Ability to maintain confidentiality and handle sensitive information with discretion.

Physical Requirements

• Prolonged periods of sitting while working on a computer and speaking on the telephone.
• Ability to remain focused during extended periods of customer interaction.
• Ability to occasionally lift up to 15 pounds.

Work Environment

This position operates in a professional office or remote work environment and requires frequent interaction with beneficiaries, Producing Agents, carrier representatives, and internal departments. During the Medicare Annual Enrollment Period (AEP), additional hours, including evenings and weekends, may be required to meet business needs.