Enrollment Specialist

Pacific Health Group•State-Wide, CA

6d•$21 - $24•Remote

About The Position

The Enrollment Specialist is responsible for helping prospective Pacific Health Group members navigate the administrative steps required to obtain and maintain healthcare coverage and become eligible for PHG services. Many individuals identified through Pacific Health Group's outreach efforts are uninsured, have inactive Medi-Cal coverage, have pending applications, need assistance completing a renewal, or are not yet enrolled with the appropriate Medi-Cal Managed Care Plan (MCP). The Enrollment Specialist takes ownership of these cases and works to move members through the coverage and enrollment process as efficiently as possible. This position assists individuals with Medi-Cal applications and renewals, monitors pending applications, follows up on eligibility issues, assists with denied or discontinued coverage, supports appeals and submission of requested documentation, helps members navigate Managed Care Plan enrollment, and tracks each case until the individual is ready to transition into PHG's applicable programs. The Enrollment Specialist serves as the administrative bridge between initial member engagement and active program enrollment, allowing care management staff to focus on members who are ready to receive services.

Requirements

High school diploma or equivalent.
Experience in healthcare administration, insurance enrollment, eligibility, social services, patient navigation, member services, or a related field.
Strong computer and data-entry skills.
Excellent telephone communication and customer service skills.
Strong attention to detail and ability to manage a large number of cases simultaneously.
Ability to independently follow cases through multiple administrative steps until resolution.
Ability to communicate effectively with individuals experiencing complex social and economic barriers.
Ability to maintain confidentiality and comply with HIPAA and organizational requirements.

Nice To Haves

Experience with Medi-Cal eligibility and enrollment.
Experience using BenefitsCal.
Knowledge of California Medi-Cal Managed Care Plans.
Experience assisting with Medi-Cal applications, renewals, appeals, or eligibility troubleshooting.
Experience working with underserved, justice-involved, unhoused, or medically complex populations.
Experience within CalAIM, Enhanced Care Management, Community Supports, managed care, or community health programs.
Bilingual skills are strongly preferred.

Responsibilities

Assist uninsured prospective members with completing and submitting Medi-Cal applications through BenefitsCal or other applicable enrollment channels.
Guide members through the application process and explain required documentation, verification requirements, and next steps.
Assist members with Medi-Cal renewals and redeterminations when coverage is approaching expiration or has been discontinued.
Help members gather and submit requested eligibility documentation.
Review applications for completeness and accuracy before submission whenever appropriate.
Educate members on the Medi-Cal enrollment process and expected next steps in clear, easy-to-understand language.
Maintain ownership of pending Medi-Cal cases from initial application through final eligibility determination.
Regularly check application and eligibility status through BenefitsCal and other approved systems.
Follow up with members, counties, health plans, and other appropriate entities regarding outstanding applications or eligibility issues.
Identify missing documentation or other barriers delaying eligibility determinations and work with members to resolve them.
Track important deadlines, notices, renewal dates, and required member actions.
Conduct persistent follow-up to prevent applications from becoming delayed, abandoned, or closed unnecessarily.
Review Medi-Cal denial, discontinuance, or request-for-information notices with members and help identify the reason for the determination.
Assist members with submitting missing documentation, corrections, reconsideration requests, appeals, or other appropriate follow-up actions.
Track appeal and reconsideration status through resolution.
Escalate complex eligibility issues to leadership or the appropriate county/agency when additional intervention is required.
Maintain detailed documentation of all actions taken and outstanding requirements.
Assist members with understanding Medi-Cal Managed Care Plan enrollment after Medi-Cal eligibility is established.
Help members navigate available MCP options within their county and complete appropriate enrollment or plan-selection processes.
Track members awaiting MCP assignment or enrollment.
Verify when MCP enrollment becomes active.
Identify members assigned to an MCP outside of PHG's contracted network and explain available next steps when appropriate.
Coordinate with internal teams once the member's coverage and MCP status allow PHG enrollment activities to proceed.
Maintain a clear pipeline of prospective members who are: Applying for Medi-Cal, Pending Medi-Cal approval, Resolving eligibility issues, Appealing a denial or discontinuance, Awaiting MCP assignment, Awaiting PHG program enrollment/authorization, Ready for handoff to the appropriate PHG team.
Verify coverage and enrollment status before transitioning members into active services.
Coordinate closely with Member Engagement, Street Outreach, ECM, Community Supports, and other departments to ensure smooth member handoffs.
Ensure all administrative prerequisites are completed before assigning eligible members to Lead Care Managers when applicable.
Communicate enrollment status and outstanding barriers clearly to internal teams.
Maintain regular contact with prospective members throughout potentially lengthy application and enrollment processes.
Explain complicated insurance and eligibility processes using clear, member-friendly language.
Contact members when additional information or documentation is required.
Provide updates regarding application status and next steps.
Help reduce member frustration and confusion by serving as a consistent point of contact throughout the enrollment process.
Identify urgent needs disclosed during enrollment conversations and escalate or connect the individual with appropriate resources according to PHG protocols.
Maintain accurate and timely documentation of every member interaction, application update, eligibility determination, appeal, MCP assignment, and outstanding action item.
Maintain organized tracking of all pending enrollment cases and their current stage.
Document unsuccessful outreach attempts and schedule appropriate follow-up.
Ensure enrollment records are accurate, complete, HIPAA-compliant, and audit-ready.
Provide leadership with regular reporting regarding pending cases, processing delays, denials, approvals, MCP assignments, and completed enrollments.