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

Bachelor's 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 30,000-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.