Eligibility Specialist

St Pauls Senior Services•SAN DIEGO, CA

About The Position

Under the supervision of the Director of Health Plan Operations, the PACE Eligibility Specialist assists current PACE participants in obtaining and maintaining Medi-Cal/Medicaid and Medicare coverage, across all PACE facilities and programs, ensuring continuous eligibility so they can access PACE services. This role involves working in a call-center setting, verifying participant/member insurance coverage, authorizations, benefits, and eligibility, assisting both providers and participants with all Health Plan related inquiries. This role will provide participant and family education, benefits counseling and available, applicable resources as necessary. This role also includes assisting with Medicaid Redeterminations and monitoring eligibility status to prevent lapses in coverage. As assigned, the Eligibility Specialist will connect with the other PACE teams to receive individualized case information, recommended approaches, care plan clarification, specific eligibility and application needs.

Requirements

Associate’s degree (AA) or equivalent from a two-year college or technical school, bachelor’s degree preferred, or equivalent combination of education and experience.
1-2+ years previous experience in eligibility assistance, case management, or Medicare/Medicaid or Managed care organizations preferred.
Strong knowledge of Medi-Cal, Medicare, and public assistance program regulations.
Ability to remain calm, professional, and solution-focused under pressure.
Strong organizational, problem solving, and customer service skills.‑solving, and customer‑service skills.
Strong attention to detail and data accuracy.
Ability to foster collaborative working relationships.
Ability to prioritize workload with strong attention to detail, recall, and recognition skills.
Ability to Maintain professionalism, patience, and strong communication while managing complex situations.
Ability to read and interpret documents such as government agency documents, safety rules, procedure manuals, and data as it relates to a participant’s eligibility.
Valid driver’s license and insurance if travel is required.

Nice To Haves

Experience working with seniors or vulnerable populations preferred.
Bilingual in Spanish preferred.

Responsibilities

Handle High-Volume Inbound Calls: respond to inquiries from both participants and providers regarding eligibility status, billing issues, and other Health Plan related questions.
Provide authorization assistance to contracted vendors for upcoming scheduled visits or emergency cases.
Assist individuals applying for or retaining Medi-Cal/Medicaid and Medicare coverage.
Assists participants with address changes with Medi-Cal and Medicare.
Maintain familiarity with local family resource centers.
Assists participants and staff with disenrollment, follow-up documentation and insurance transition.
Stay Current with Program Regulations: Participate in training and updates to ensure accurate information is communicated during calls.
Explain eligibility requirements, benefits, and coverage options to participants and families.
Identify and resolve enrollment-related issues (e.g., hospice flags, out-of-area situations, accidental disenrollments, retroactive eligibility).
Assist with resolving problems related to benefits, documentation, or eligibility barriers.
Acts as liaison and advocate for participant, caregivers and community agencies regarding participant benefits.
Collaborate with Social Workers, Billing Specialists, Intake, and other PACE team members to resolve eligibility issues.
Work with state agencies to resolve Medi-Cal issues including over-resources or documentation problems.
Submit and track applications, renewals, and required documentation in accordance with DHCS, CMS, and county timelines.
Conduct Phone-Based and Home Visit Interviews as needed to collect and verify financial, demographic, and household information required for eligibility determination.
Assist participants at external offices when necessary (county social services, DMV, Social Security, banks, etc.).
Educate staff, participants, and families regarding eligibility processes and updates.
Provides ongoing support and education to participants and family regarding a variety of issues, including but not limited to: PACE model and PACE eligibility criteria.
Support orientation and training for new team members and cross-functional teams, as needed.
Write up and maintain standard operating procedures (SOP) for all processes.
Follows all St. Paul’s PACE Policies and Procedures and OSHA safety guidelines.
Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
Other duties as assigned.