Eligibility Manager

INNOVATIVE INTEGRATED HEALTH•Fresno, CA

2d•$70,304 - $85,000•Onsite

About The Position

The Eligibility Manager is responsible for leading and overseeing the Eligibility department within the Finance team for IIH PACE. This position is accountable for ensuring accurate and timely determination, maintenance, and optimization of participant eligibility and enrollment, which directly maximizes revenue and minimizes financial risk. The Eligibility Manager provides strategic direction, leadership, and supervision to the Eligibility Supervisor and Eligibility Specialists while ensuring full compliance with all state and federal regulations, including Medi-Cal and Medicare requirements. This role requires close collaboration with multiple departments (Claims, Intake, Social Work, and others) to resolve complex eligibility issues and drive process improvements. Travel to other Innovative Integrated Health may be necessary on occasion for coverage needs and management oversight.

Requirements

Strong leadership and people management skills with the ability to motivate, develop, and hold team members accountable.
Expert knowledge of Medi-Cal, Medicare, and PACE eligibility and enrollment requirements.
Proficient in Microsoft Office (Word, Excel, PowerPoint, Outlook) and ability to quickly learn organizational systems.
Excellent analytical, problem-solving, and critical thinking skills.
Superior verbal and written communication skills.
High level of attention to detail combined with strong organizational and time management abilities.
Ability to manage multiple priorities in a fast-paced environment and adapt to changing regulations.
Demonstrated ability to work independently and collaboratively across departments.
Strong understanding of revenue cycle processes as they relate to eligibility and enrollment.
Minimum of five (5) years of progressive experience in eligibility, enrollment, or revenue cycle management within a managed care organization required, preferably in a PACE or senior care setting.
Minimum of three (3) years of supervisory or managerial experience required.
Bachelor’s degree in Business Administration, Healthcare Administration, or related field required
Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.

Nice To Haves

In-depth knowledge of Medi-Cal and Medicare regulations strongly preferred.
Master’s Degree preferred.

Responsibilities

Provide leadership, supervision, and mentorship to the Eligibility Supervisor and all Eligibility Specialists, including performance management, training, and professional development.
Responsible for performance management of departmental employees, including recognition, performance evaluations, formal coaching and counseling, and making decisions or recommendations regarding necessary disciplinary actions.
Oversee daily operations of the Eligibility team to ensure timely and accurate processing of participant enrollments, disenrollments, and eligibility determinations.
Ensure compliance with all Medi-Cal, Medicare, and PACE eligibility and enrollment regulations, including ongoing monitoring of regulatory updates from DHCS, CMS, and other agencies.
Oversee the review and reconciliation of 820/834 files, Daily Transaction Reply Reports (DTRRs), and other eligibility transaction files.
Develop, implement, and continuously improve policies, procedures, and workflows related to eligibility determination, retrospective/prospective enrollments, disenrollments, Share of Cost (SOC), out-of-area issues, and excluded benefits.
Serve as the primary point of escalation for complex eligibility and enrollment issues, working collaboratively with Intake, Social Work, Claims, and other departments to achieve timely resolutions.
Manage internal and external eligibility verification processes, including responses to CMS review packages and audits via Electronic Retroactive Processing Transmission.
Analyze eligibility-related accounts receivable, identify trends and opportunities for revenue optimization, and implement corrective action plans
Prepare regular reports and dashboards on eligibility metrics, team performance, and compliance for the Director of Finance and senior leadership.
Lead or participate in cross-functional projects, committees, and initiatives aimed at improving participant experience and operational efficiency.
Maintain expert-level knowledge of PACE, Medi-Cal, and Medicare eligibility rules and serve as the subject matter expert for the organization.
Attend and actively participate in staff meetings, in-services, and required training.
Adhere to and promote company policies, procedures, and core values.
Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
Be flexible in schedule of hours worked.
May be required to use a personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required.