Eligibility and Operations Specialist (OhioRISE)

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Business Overview

As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, OhioRISE will help struggling children and their families by focusing on the individual, with strong coordination and partnership among MCOs (Managed Care Organizations), vendors, and ODM (Ohio Department of Medicaid) to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.

Position Summary

The Eligibility and Operations Specialist plays a key role in managing and reconciling OhioRISE eligibility and CME (Care Management Entity) enrollment issues. The Eligibility and Operations Specialist will provide support on a wide range of complex enrollment activities. This person is responsible for ensuring prompt and accurate enrollment information achieved through daily enrollment report reviews.

This person reports to the Chief Operating Officer and works in close partnership with the Director of the CME Alliance Hub, as well as all matrixed growth partners, to effectively support our CME partners, as well as the youth and families in their care.

Responsibilities include:

• Reconcile ODM eligibility files with CME membership files to ensure the accuracy of CME assignments.
• Daily review of enrollment reports to research and resolve errors in eligibility coverage breaks, correct duplicate member ID numbers, and monitor retro Medicaid reinstatements for downstream impact on claims.
• Serve as health plan representative for enrollment revenue reconciliation meetings.
• Oversee enrollment reporting and ad hoc requests.
• Use databases and Microsoft Excel to identify and analyze trends in data.
• Identify manual processes for automation opportunities.
• Review error reports and process file fallouts.
• Oversee various updates of workflows and policy & procedures.
• Provide thorough, timely, and accurate resolution of reconciliation disputes and escalated complex cases via telephone, email, and other methods.
• Accurately research and resolve data discrepancies to ensure data integrity across external partners.
• Other duties as assigned.

Required Qualifications

• 3-5 years of experience with Medicaid and/or managed care operations and/or enrollment processes.
• Must reside in Ohio.
• Demonstrated proficiency with personal computer, keyboard navigation skills and with Microsoft Office Suite applications (Outlook, Word, Excel, PowerPoint, SharePoint, etc.)

Preferred Qualifications

• Demonstrated relationship management skills; capacity to quickly build and maintain credible relationships at varying levels (externally and within the organization).
• Strong organization skills, creativity, and member-focused approach.
• Excellent communication skills.
• Adept at interdepartmental collaboration.
• Associate’s or Bachelor’s degree.

Education

• High school diploma or GED.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$21.10 - $36.78

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 01/13/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.