What Does a Healthcare Enrollment Specialist Do?
A healthcare enrollment specialist helps patients, employees, or plan participants enroll in health insurance coverage and ensures they maintain accurate and timely eligibility. These professionals work in hospitals, health systems, insurance companies, or government programs, facilitating enrollment for Medicare, Medicaid, Affordable Care Act (ACA) plans, or employer-sponsored benefits. They guide individuals through choosing appropriate plans, completing required documentation, and navigating plan rules and deadlines.
This role requires a mix of healthcare policy knowledge, administrative skill, and emotional intelligence. Enrollment specialists must understand eligibility requirements, maintain compliance with HIPAA and other healthcare regulations, and communicate complex insurance concepts in ways that are easy to understand. They often assist people during moments of financial or medical uncertainty, so compassion and clarity are essential. They also serve as a critical link between payers, patients, and providers, ensuring that individuals have the coverage they need to access timely care.
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Healthcare Enrollment Specialist Core Responsibilities
- Facilitate the enrollment of patients or plan members in healthcare coverage, including Medicaid, Medicare, ACA, or employer-sponsored plans
- Assist individuals in understanding available plan options and eligibility criteria
- Review, process, and track insurance applications and enrollment forms
- Verify patient or member information and input accurate data into healthcare enrollment platforms
- Respond to inquiries regarding benefits, eligibility, and coverage status
- Communicate with insurance providers and third-party administrators to confirm enrollment or resolve discrepancies
- Ensure compliance with all applicable healthcare laws, including HIPAA, ACA, and CMS guidelines
- Provide documentation and assistance during audits or enrollment reviews
- Maintain thorough records of interactions, applications, and eligibility status
- Coordinate with internal departments such as billing, case management, or HR to ensure alignment across patient records
Required Skills and Qualifications
Hard skills
- Working knowledge of health insurance terminology and plan structures (e.g., PPO, HMO, Medicare Advantage)
- Proficiency in enrollment platforms and data entry systems
- Familiarity with HIPAA and ACA compliance requirements
- Ability to interpret and apply eligibility criteria and federal/state healthcare regulations
- Basic understanding of EDI (electronic data interchange) in healthcare
Soft skills
- Empathetic, patient-first communication style
- Strong attention to detail and accuracy in data handling
- Analytical thinking and problem-solving for eligibility questions
- Ability to handle sensitive or confidential information with discretion
- Adaptability to regulatory and process changes
Education
- High school diploma or equivalent required
- Associate’s degree in healthcare administration, public health, or related field preferred
Certifications
- Certified Application Counselor (CAC) required for ACA marketplace roles
- State-specific insurance licensing may be required for certain employers
- Additional recommended credentials include HIPAA compliance certification or certification as a Certified Healthcare Access Associate (CHAA)
Preferred Qualifications
- Bilingual fluency, particularly in Spanish, is highly preferred
- Experience enrolling individuals in government or public health programs
- Familiarity with benefits administration platforms such as Benefitfocus, Workday, or Oracle
- Previous work in a hospital, managed care organization, or insurance company
- Comfort handling high call or case volumes with minimal supervision
National Average Salary
Healthcare enrollment specialist salaries vary by experience, industry, organization size, and geography. Click below to explore salaries by local market.
The average national salary for a Healthcare Enrollment Specialist is:
$53,575
Sample Job Description Templates for Healthcare Enrollment Specialists
Medicaid Enrollment Specialist
Position Overview
We are seeking a dedicated Medicaid Enrollment Specialist to support patients in applying for and maintaining Medicaid coverage. This role involves working closely with state health agencies, healthcare providers, and patients to ensure eligibility is accurately determined and documented. The ideal candidate will have experience with public health programs, strong administrative skills, and the ability to communicate complex information with empathy and clarity.
Responsibilities
- Assist patients with Medicaid applications, renewals, and required documentation
- Screen for eligibility based on income, household size, and state criteria
- Enter and update applicant information in state and internal databases
- Coordinate with state agencies to verify application status and resolve discrepancies
- Provide clear guidance on Medicaid plan options and enrollment deadlines
- Maintain compliance with HIPAA and all state-specific Medicaid rules
- Track enrollment metrics and flag delays or denials for escalation
- Collaborate with clinical staff to secure retroactive or emergency Medicaid when applicable
Requirements
Hard skills
- Knowledge of Medicaid eligibility guidelines and documentation requirements
- Experience with state enrollment portals or eligibility verification systems
- Proficiency in secure data entry and benefits tracking software
Soft skills
- Compassionate, service-oriented communication
- Ability to handle sensitive financial and medical information
- Multitasking under pressure in high-need environments
- Attention to detail in compliance-driven processes
Education
- High school diploma or GED required
- Associate’s degree in healthcare, social work, or public administration preferred
Certifications
- HIPAA compliance certification required
- State-specific Medicaid training or enrollment certification preferred
Preferred Qualifications
- Bilingual language skills highly preferred
- Experience working in community health or hospital-based Medicaid assistance
- Familiarity with Medicaid managed care plans or state waiver programs
Medicare Enrollment Specialist
Position Overview
We are hiring a Medicare Enrollment Specialist to guide individuals through enrollment in Original Medicare, Medicare Advantage, and Part D plans. This role supports beneficiaries during initial, special, and annual enrollment periods, ensuring all forms and communications meet CMS standards. Successful candidates will have deep knowledge of federal healthcare programs and strong organizational skills.
Responsibilities
- Educate eligible individuals about Medicare parts, plan options, and enrollment timelines
- Assist with completing and submitting enrollment forms accurately and on time
- Confirm eligibility using CMS databases or insurer platforms
- Communicate plan benefits, premium costs, and coverage gaps clearly
- Ensure compliance with CMS guidelines, including disclosure and documentation rules
- Track status of applications and follow up with carriers and clients as needed
- Maintain confidential enrollment records for audit readiness
Requirements
Hard skills
- Understanding of Medicare Part A, B, C, and D coverage rules
- Familiarity with CMS enrollment procedures and compliance expectations
- Experience using Medicare Plan Finder and related eligibility tools
Soft skills
- Strong verbal communication with elderly or disabled populations
- Clear, compassionate guidance through complex decisions
- Accountability in meeting strict submission deadlines
- Analytical thinking to resolve eligibility or documentation issues
Education
- High school diploma or GED required
- Associate’s degree or coursework in healthcare or insurance preferred
Certifications
- CMS training and certification required for enrollment specialists
- HIPAA compliance certification required
Preferred Qualifications
- Previous experience assisting seniors or disabled populations
- Experience with Medicare Savings Programs or dual eligibility cases
- Familiarity with Medicare marketing guidelines for plan comparisons
ACA Marketplace Enrollment Specialist
Position Overview
We’re looking for an ACA Marketplace Enrollment Specialist to support individuals applying for health coverage through Healthcare.gov or state-based exchanges. The role involves verifying eligibility for subsidies, explaining coverage tiers, and guiding applicants through the submission of complex documentation. Ideal candidates are patient educators with strong compliance awareness and technical fluency.
Responsibilities
- Assist consumers with account creation, application submission, and plan selection through federal or state exchanges
- Explain eligibility for premium tax credits, cost-sharing reductions, and coverage tiers
- Verify identity and income through documentation and third-party tools
- Ensure accuracy and completeness of all application fields and submitted files
- Educate applicants about enrollment deadlines, penalties, and SEP requirements
- Maintain HIPAA compliance in digital and physical documentation
- Follow CMS training requirements and maintain current certification
Requirements
Hard skills
- Familiarity with the Affordable Care Act, FPL-based eligibility rules, and subsidies
- Experience using the Healthcare.gov portal or state exchange platforms
- Proficient in scanning, uploading, and verifying digital documentation
Soft skills
- Patient education and issue de-escalation
- Clear written and verbal communication
- Empathy for applicants navigating financial hardship
- Problem-solving across insurance, identity, and eligibility challenges
Education
- High school diploma or GED required
- Associate’s degree in healthcare or social services preferred
Certifications
- Certified Application Counselor (CAC) or Navigator certification required
- HIPAA certification required
Preferred Qualifications
- Experience with special enrollment periods (SEP) and life event documentation
- Fluency in Spanish or other high-demand languages
- Familiarity with immigration statuses relevant to ACA eligibility
Employee Benefits Enrollment Specialist
Position Overview
We are seeking an Employee Benefits Enrollment Specialist to manage health benefit enrollments during new hire onboarding and annual open enrollment periods. This role acts as a liaison between HR, insurance carriers, and employees to ensure accurate and timely coverage activation. A strong understanding of employer-sponsored benefits and insurance platforms is essential.
Responsibilities
- Coordinate health, dental, vision, and supplemental insurance enrollments for employees
- Review eligibility and ensure completion of new hire and open enrollment forms
- Work with HRIS and benefits platforms to input and audit enrollment data
- Resolve discrepancies with carriers and assist employees with benefit-related inquiries
- Maintain up-to-date records and track enrollment milestones
- Educate employees on plan options, coverage levels, and deductions
- Ensure compliance with ERISA, COBRA, and HIPAA standards
Requirements
Hard skills
- Proficiency in benefits administration software (e.g., Workday, ADP, Benefitfocus)
- Familiarity with ERISA, COBRA, and ACA employer mandates
- Data accuracy in HRIS and carrier systems
Soft skills
- Clear, professional communication with employees at all levels
- Confidentiality and discretion in handling sensitive personal data
- Organizational skills and time management under tight deadlines
- Patience and clarity during benefits education sessions
Education
- High school diploma or GED required
- Associate’s or bachelor’s degree in HR, business, or healthcare preferred
Certifications
- HIPAA certification required
- Certified Employee Benefit Specialist (CEBS) is a plus
Preferred Qualifications
- Experience supporting large-scale open enrollment periods
- Previous work in a corporate HR or benefits department
- Familiarity with wellness programs or flexible spending accounts (FSAs)
Remote Enrollment Specialist
Position Overview
We are hiring a Remote Enrollment Specialist to manage healthcare coverage enrollment from a virtual setting. This role requires independent initiative, tech fluency, and secure handling of confidential data. You’ll support applicants by phone, email, and video, guiding them through eligibility, documentation, and plan selection without in-person contact.
Responsibilities
- Process healthcare enrollments via secure virtual platforms
- Provide support and guidance on plan eligibility, applications, and documentation
- Upload, review, and submit digital enrollment materials
- Maintain HIPAA and data security protocols in a home office environment
- Coordinate with providers, agencies, and applicants via virtual tools
- Track enrollment outcomes and maintain detailed case records
Requirements
Hard skills
- Proficiency with digital communication tools (Zoom, Slack, email platforms)
- Familiarity with EHR and benefits platforms used in remote workflows
- Secure data entry using encrypted systems or VPN
Soft skills
- High degree of self-motivation and accountability
- Strong written and verbal clarity across digital channels
- Comfort working independently and resolving issues remotely
- Customer-first mindset in virtual interactions
Education
- High school diploma or GED required
Certifications
- HIPAA compliance certification required
- Remote workforce readiness or telehealth training preferred
Preferred Qualifications
- Prior experience as a remote customer service or healthcare enrollment agent
- Fluency in more than one language
- Background in serving rural or underserved populations through digital platforms