Eligibility and Operations Specialist; OhioRISE

Eligibility and Operations Specialist (OhioRISE)

Join to apply for the Eligibility and Operations Specialist (OhioRISE) role at CVS Health

As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, OhioRISE will help children and families by coordinating care across Managed Care Organizations, vendors, and the Ohio Department of Medicaid. The program provides comprehensive behavioral health services for children with serious or complex needs who are involved in or at risk for involvement in multiple child-serving systems.

The Eligibility and Operations Specialist manages and reconciles OhioRISE eligibility and Care Management Entity (CME) enrollment issues, ensuring accurate enrollment information through daily report reviews and partnership with CME partners and families.

• Reconcile ODM eligibility files with CME membership files to ensure accuracy of CME assignments.
• Daily review of enrollment reports to research and resolve errors in eligibility coverage breaks, correct duplicate member , 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 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.

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

• Relationship management skills; capacity to build and maintain credible relationships at varying levels.
• Strong organization skills, creativity, and member-focused approach.
• Excellent communication skills.
• Adept at interdepartmental collaboration.
• Associate’s or Bachelor’s degree.

• High school diploma or GED.

40

Full time

The Typical Pay Range For This Role Is $21.10 - $36.78

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:
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

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.