Medi-Cal Eligibility Resolution Specialist - San Diego

Medi-Cal Eligibility Resolution Specialist

Position: Medi-Cal Eligibility Resolution Specialist

Pay Range: $27.00-$30.00 PER HR

Reporting To: Lead Medi-Cal Eligibility Resolution Specialist

Work Type: Remote/Field

Position Summary:

The Medi-Cal Eligibility Resolution Specialist is responsible for identifying, resolving, and preventing Medi-Cal eligibility issues that impact member access to services or hinder reimbursement. This role ensures timely coordination of Medi-Cal redeterminations, collaborates with county eligibility offices, and supports members through complex eligibility processes. The position is primarily remote, with required field visits to county Medi-Cal offices when in-person resolution is more effective. Specialists are assigned to specific counties or regions to build strong local relationships and expedite issue resolution.

Qualifications:

• Strong knowledge of Medi-Cal eligibility and public benefit programs
• Knowledge of Medi-Cal eligibility rules and redetermination processes.
• Experience in working with electronic healthcare systems, and state eligibility systems.
• Familiar with Microsoft Word and Excel programs.
• Strong analytical, organizational and communication skills.
• Strong communication skills.
• Experience in a health plan, county eligibility office or healthcare revenue cycle.
• Bilingual in Spanish preferred.
• Experience resolving insurance denials or appeals.
• Preferably, has a bachelor's degree in healthcare, business administration or related field.

Essential Duties And Responsibilities:

The following is a representation of the major duties and responsibilities of this position. The agency will make reasonable accommodations to allow otherwise qualified applicants with disabilities to perform essential functions.

• Investigate and resolve Medi-Cal eligibility barriers that prevent members from accessing services or disrupt reimbursement workflows.
• Conduct eligibility verification using state systems, EMR platforms, and insurance databases.
• Communicate with county eligibility workers to clarify case status and resolve pending or denied actions.
• Oversee and coordinate Medi-Cal redetermination submissions.
• Track redetermination cycles and proactively engage members.
• Contact members to gather required information and explain eligibility requirements.
• Build relationships with county Medi-Cal offices.
• Collaborate with internal departments including Member Services, Revenue Cycle, Clinical Teams, and Compliance.
• Maintain accurate, audit-ready documentation.
• Conduct in-person visits to county offices when necessary.
• Track and report eligibility trends and case outcomes.
• Driving will be required to county offices.
• Maintain confidentiality, HIPAA compliance, and knowledge of mandated reporting requirements.
• Uphold agency standards, policies, and procedures as outlined in the Employee Handbook.
• Participate in departmental meetings and trainings as required.
• Performs other duties as assigned.

Physical Requirements:

• Stand, sit, talk, hear, and use of hands and fingers to operate computer, telephone, and keyboard on a frequent basis up to 40% of the time.
• Reach, stoop, kneel and bend up to 20% of the time
• Moderate amount of walking up to 15% of the time.
• Moderate amount of driving up to 25% of the time.
• Close vision requirements due to computer work on a frequent basis
• Light to moderate lifting may be required up to 25lbs on a frequent basis.
• Pushing and pulling up to 25lbs.