Eligibility Specialist

Eligibility SpecialistHybrid • Fresno - Fresno, CA 93721OverviewSalary Range $20.00 - $24.00 Hourly Level Entry Position Type Full Time Job Shift Day Category FinanceDescriptionWho We ArePACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant. Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive.Benefits401(k)Dental insuranceEmployee assistance programEmployee discountFlexible spending accountHealth insuranceHealth savings accountLife insurancePaid sick timePaid time offReferral programRetirement planVision insuranceJob SummaryUnder the supervision of the Eligibility Manager, the Eligibility Specialist is responsible for supporting the accurate determination, verification, maintenance, and reinstatement of participant eligibility and enrollment in the Program of All-Inclusive Care for the Elderly (PACE). This role focuses on monitoring and coordinating Medicare and Medi-Cal eligibility, managing annual redetermination, coordination of benefits (COB), retroactive enrollments/reinstatements, and resolving eligibility-related accounts receivable issues. The specialist ensures compliance with state and federal regulations while contributing to the financial and operational goals of the Finance department. The Eligibility Specialist works collaboratively with the Intake, Social Work, Claims, Pharmacy, and Interdisciplinary Team (IDT) to facilitate timely enrollment, redetermination, reinstatements, and COB processes, while providing participant-centered care for frail elderly individuals in the PACE program.Essential Job FunctionsEligibility Monitoring and Verification: Monitor and track daily participant eligibility and enrollment status as reported by the Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS).Review and reconcile 820/834 eligibility and payment files from DHCS and Daily Transaction Reply Reports (DTRRs) from CMS.Track Medicare entitlement dates and work closely with the Intake team to ensure timely and accurate enrollment into the PACE program.Medi-Cal Redetermination Assistance Track upcoming Medi-Cal annual redeterminations (financial, categorical, and residency) at least 120 days in advance using DHCS 834 reports, MEDS data, and internal records.Conduct outreach (phone, mail, in-person, text) and document consent for assistance using authorized representative forms (e.g., MC382/MC383).Assist participants/representatives with gathering verifications, completing forms, and submitting renewals to the county (via portal, mail, or e-fax) during the process and 90-day cure period.Follow up on status, assist with appeals or reapplications if needed, and notify IDT of any potential coverage gaps.Maintain the Medi-Cal Redetermination Assistance Checklist in Excel for tracking and reporting.Reinstatement and Retroactive Enrollment Support Identify cases of accidental enrollment in another Medicare plan and Medi-Cal-only participants turning 65.Perform outreach, obtain consent, and gather required documentation (signed Enrollment Agreement, IDT assessments, eligibility verifications).Coordinate disenrollment from other plans and prepare/submit retroactive requests to the CMS Retroactive Processing Contractor (RPC) within 90 days (or escalate older cases).Submit DHCS Enrollment/Disenrollment Request Logs per policy letters.Align dates for age-related Medicare entitlement transitions and ensure seamless PACE coverage.Maintain the Reinstatement Tracking Log in Excel and report outcomes to leadership.Coordination of Benefits (COB) and Other Payer Management 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 for point-of-sale adjudication, TrOOP accumulator management, and Automated TrOOP Balance Transfer (ATBT)/FIR processes via Relay Health.Notify participants of other coverage information, resolve discrepancies, and support payment recovery where PACE is secondary.Reconcile CMS files (MBD, MARx) and support TrOOP/gross covered drug cost transfers upon disenrollment.Enrollment, Disenrollment, and Cross-Departmental Support: Update and maintain enrollment/eligibility databases, tracking spreadsheets, and participant records.Assist all departments in confirming and verifying participant eligibility for internal use and external inquiries (providers, CMS, 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.Compliance and Team Collaboration: Maintain current knowledge of PACE eligibility, enrollment, redetermination, reinstatement, retroactive processing, and COB requirements under CMS (42 CFR Part 460) and DHCS regulationsOccasional travel to participants' homes, PACE centers, or county offices may be required for outreach, redetermination assistance, eligibility coordination, or other job-related duties. Attend and actively participate in staff meetings, in-services, quality improvement projects, and assigned committees.Adhere to all center policies, procedures, and HIPAA/privacy requirements.Be flexible with work schedule as needed and perform other related duties as assigned.May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California Driver's License is required.QualificationsKnowledge, Skills and AbilitiesProficient in MS Office (Word, Excel, Access, PowerPoint, Outlook) with strong Excel skills for tracking logs and reporting.Knowledge of general office procedures, equipment, and filing systems.Effective oral and written communication skills, including the ability to interact professionally with participants, families, and internal/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 while functioning 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.Working Conditions and Physical DemandsAbility to access all areas of the center throughout the workday.Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee when attempting to lift or transfer objects over 50 pounds.Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.Ability to communicate verbally with an excellent comprehension of the English language.Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment.ExperienceMinimum of two (2) years of professional experience in a managed care organization, healthcare eligibility, enrollment, or coordination of benefits role required or in lieu of experience, an Associate's Degree.Experience with Medicare and/or Medi-Cal eligibility, redetermination, and PACE processes strongly preferred.Familiarity with DHCS and CMS systems (834 files, DTTRs, ECRS, MARx,