Eligibility Specialist

INNOVATIVE INTEGRATED HEALTH•Fresno, CA

1d•$20 - $24•Onsite

About The Position

The Eligibility Specialist supports accurate determination, verification, maintenance, and reinstatement of participant eligibility and enrollment in the Program of All-Inclusive Care for the Elderly (PACE). Under the supervision of the Eligibility Manager, this position monitors Medicare and Medi-Cal eligibility, annual redeterminations, coordination of benefits, retroactive enrollments and reinstatements, and eligibility-related accounts receivable issues. The role helps ensure compliance with state and federal regulations while supporting the Finance department’s financial and operational goals. The specialist collaborates with Intake, Social Work, Claims, Pharmacy, and the Interdisciplinary Team (IDT) to facilitate enrollment, redetermination, reinstatement, and coordination-of-benefits processes. The position supports participant-centered care for frail elderly people in the PACE program. Occasional travel to participants’ homes, PACE centers, or county offices may be required. The role requires flexibility with work schedules as needed and may require use of a personal vehicle; a valid California Driver’s License is required if using a personal vehicle. Work is generally performed indoors in a well-lighted, well-ventilated, heated, and air-conditioned environment. The employee must be able to access all areas of the center throughout the workday and meet the listed lifting, dexterity, movement, and communication requirements. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Requirements

At least two years of professional experience in a managed care organization, healthcare eligibility, enrollment, or coordination of benefits role, or an Associate’s Degree in lieu of that experience.
At least one year of documented experience working with a frail or elderly population.
Associate’s Degree in Business Administration, Healthcare Administration, or a related field, or the stated qualifying professional experience.
CPR with First-Aid certification.
Medical clearance for communicable diseases and up-to-date immunizations before direct participant contact.
Proficiency in MS Office, including Word, Excel, Access, PowerPoint, and Outlook; strong Excel skills for tracking logs and reporting.
Knowledge of general office procedures, equipment, and filing systems.
Effective oral and written communication skills and the ability to interact professionally with participants, families, and internal and external stakeholders.
Strong attention to detail, accuracy, and organizational skills, with the ability to manage multiple priorities.
Knowledge of Medi-Cal and Medicare eligibility rules, aid codes, Share of Cost, PACE enrollment, redetermination, reinstatement, retroactive processes, and COB/TrOOP requirements.
Ability to work independently with minimal supervision and as part of a collaborative team.
Commitment to participant-centered care and the PACE model of supporting frail elders to remain independent in the community.
Ability to access all areas of the center throughout the workday.
Ability to lift at least 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; assistance from another employee is required when attempting to lift or transfer objects over 50 pounds.
Constant hand grasp and finger dexterity; frequent sitting, standing, walking, and repetitive leg and arm movements; occasional bending, forward and overhead reaching, squatting, and kneeling.
Ability to communicate verbally with excellent comprehension of English.
Valid California Driver’s License if using a personal vehicle.

Nice To Haves

Experience with Medicare and/or Medi-Cal eligibility, redetermination, and PACE processes.
Familiarity with DHCS and CMS systems, including 834 files, DTRRs, ECRS, MARx, and Relay Health.

Responsibilities

Monitor and track daily participant eligibility and enrollment status reported by DHCS and CMS.
Review and reconcile DHCS 820/834 eligibility and payment files and CMS Daily Transaction Reply Reports (DTRRs).
Track Medicare entitlement dates and coordinate with Intake to support timely, accurate PACE enrollment.
Track upcoming Medi-Cal annual redeterminations at least 120 days in advance using DHCS 834 reports, MEDS data, and internal records.
Conduct outreach by phone, mail, in person, or text; document consent for assistance using authorized representative forms.
Help participants or representatives gather verifications, complete forms, and submit renewals to the county during the renewal process and 90-day cure period.
Follow up on redetermination status, assist with appeals or reapplications when needed, and notify the IDT of potential coverage gaps.
Maintain the Medi-Cal Redetermination Assistance Checklist in Excel for tracking and reporting.
Identify accidental enrollment in another Medicare plan and Medi-Cal-only participants turning 65; conduct outreach, obtain consent, and gather required documentation.
Coordinate disenrollment from other plans and prepare and submit retroactive requests to the CMS Retroactive Processing Contractor within 90 days, escalating older cases.
Submit DHCS Enrollment/Disenrollment Request Logs according to policy letters and align dates for age-related Medicare entitlement transitions.
Maintain the Reinstatement Tracking Log in Excel and report outcomes to leadership.
Conduct initial and annual screenings for other prescription drug coverage and other payers.
Submit timely notifications to the CMS COB Contractor via ECRS and coordinate with the contracted PBM on point-of-sale adjudication, TrOOP accumulator management, and ATBT/FIR processes via Relay Health.
Notify participants about other coverage information, resolve discrepancies, and support payment recovery when PACE is the secondary payer.
Reconcile CMS MBD and MARx files and support TrOOP/gross covered drug cost transfers upon disenrollment.
Update and maintain enrollment and eligibility databases, tracking spreadsheets, and participant records.
Assist departments with confirming and verifying participant eligibility for internal use and external inquiries from providers, CMS, and DHCS.
Collaborate with Intake, Social Work, Claims, and Pharmacy teams to resolve eligibility, redetermination, reinstatement, and COB barriers.
Communicate resolutions clearly and supportively to participants and families.
Maintain current knowledge of PACE eligibility, enrollment, redetermination, reinstatement, retroactive processing, and COB requirements under CMS and DHCS regulations.
Attend and actively participate in staff meetings, in-services, quality improvement projects, and assigned committees.
Follow center policies and procedures and HIPAA/privacy requirements; perform other related duties as assigned.