Highdesertpace
Description
The Eligibility Specialist is responsible for managing and supporting participant enrollment and post-enrollment activities for Medi-Cal and Medicare programs, ensuring accuracy, compliance, and continuity of coverage. Requirements
Responsibilities
Collaborate with Medi-Cal Specialist to complete redeterminations in a timely manner. Monitor and maintain participants’ Medi-Cal and Medicare eligibility, including managing recertification processes and ensuring no lapses in coverage. Identify and resolve enrollment issues, such as hospice flags, out-of-service-area enrollments, and accidental disenrollments. Submit IHSS waivers to the county. Work on retroactive enrollment issues by gathering and submitting proof of service and other necessary documentation. Track members eligible for Medicare applications and collaborate with Social Work team to process applications. Adhere strictly to DHCS and CMS regulations and policies, particularly regarding ethical marketing practices for the PACE Program. Process Share of Cost transactions via DHCS online portal and resolve any discrepancies. Monitor and track revenue for both Medicare and Medi-Cal participants. Perform other duties as assigned, supporting team goals, and organizational compliance. Education & Training
Associate degree or higher preferred Minimum two years’ experience working in case management, Medi-Cal eligibility, and clinical documentation required One year experience working with the elderly, PACE, or the Medi-Cal process preferred Skills & Abilities
Work independently and as an effective member of a team. Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, members, providers and the public. Communicate effectively, both verbally and in writing, with individuals from varying cultural backgrounds. Prepare concise and clear reports. Effectively utilize computer and appropriate software and interact as needed with High Desert PACE Information Systems. Foster and model an effective team environment, where each team member is held accountable for their independent work. Approach leadership with an openness to new ideas, cultural humility and acknowledgment of the dynamics of privilege. Knowledge of
Principles and practices of health care, health care systems, and managed care Medi-Cal benefits and regulations Community-based organizations, agencies, and community services Team and value-based care Regulatory policies, rules, and regulations Working Conditions
The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Primarily, work indoors. Are exposed daily to participants who have diseases or infections. Wear protective clothing such as a gown, masks, and gloves, as needed. While performing the duties of this job, the employee is frequently required to walk, sit, and/or stand. The employee must occasionally lift and/or move up to 25 pounds.
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The Eligibility Specialist is responsible for managing and supporting participant enrollment and post-enrollment activities for Medi-Cal and Medicare programs, ensuring accuracy, compliance, and continuity of coverage. Requirements
Responsibilities
Collaborate with Medi-Cal Specialist to complete redeterminations in a timely manner. Monitor and maintain participants’ Medi-Cal and Medicare eligibility, including managing recertification processes and ensuring no lapses in coverage. Identify and resolve enrollment issues, such as hospice flags, out-of-service-area enrollments, and accidental disenrollments. Submit IHSS waivers to the county. Work on retroactive enrollment issues by gathering and submitting proof of service and other necessary documentation. Track members eligible for Medicare applications and collaborate with Social Work team to process applications. Adhere strictly to DHCS and CMS regulations and policies, particularly regarding ethical marketing practices for the PACE Program. Process Share of Cost transactions via DHCS online portal and resolve any discrepancies. Monitor and track revenue for both Medicare and Medi-Cal participants. Perform other duties as assigned, supporting team goals, and organizational compliance. Education & Training
Associate degree or higher preferred Minimum two years’ experience working in case management, Medi-Cal eligibility, and clinical documentation required One year experience working with the elderly, PACE, or the Medi-Cal process preferred Skills & Abilities
Work independently and as an effective member of a team. Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, members, providers and the public. Communicate effectively, both verbally and in writing, with individuals from varying cultural backgrounds. Prepare concise and clear reports. Effectively utilize computer and appropriate software and interact as needed with High Desert PACE Information Systems. Foster and model an effective team environment, where each team member is held accountable for their independent work. Approach leadership with an openness to new ideas, cultural humility and acknowledgment of the dynamics of privilege. Knowledge of
Principles and practices of health care, health care systems, and managed care Medi-Cal benefits and regulations Community-based organizations, agencies, and community services Team and value-based care Regulatory policies, rules, and regulations Working Conditions
The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Primarily, work indoors. Are exposed daily to participants who have diseases or infections. Wear protective clothing such as a gown, masks, and gloves, as needed. While performing the duties of this job, the employee is frequently required to walk, sit, and/or stand. The employee must occasionally lift and/or move up to 25 pounds.
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