Medi-Cal Eligibility Resolution Specialist - San Diego

Job Description

Job Description

JOB DESCRIPTION

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:

1. Strong knowledge of Medi-Cal eligibility and public benefit programs
2. Knowledge of Medi-Cal eligibility rules and redetermination processes.
3. Experience in working with electronic healthcare systems, and state eligibility systems.
4. familiar with Microsoft Word and Excel programs.
5. Strong analytical, organizational and communication skills.
6. Strong communication skills.
7. Experience in a health plan, county eligibility office or healthcare revenue cycle.
8. Bilingual in Spanish preferred.
9. Experience resolving insurance denials or appeals.
10. 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.

1. Investigate and resolve Medi-Cal eligibility barriers that prevent members from accessing services or disrupt reimbursement workflows.
2. Conduct eligibility verification using state systems, EMR platforms, and insurance databases.
3. Communicate with county eligibility workers to clarify case status and resolve pending or denied actions.
4. Oversee and coordinate Medi-Cal redetermination submissions.
5. Track redetermination cycles and proactively engage members.
6. Contact members to gather required information and explain eligibility requirements.
7. Build relationships with county Medi-Cal offices.
8. Collaborate with internal departments including Member Services, Revenue Cycle, Clinical Teams, and Compliance.
9. Maintain accurate, audit-ready documentation.
10. Conduct in-person visits to county offices when necessary.
11. Track and report eligibility trends and case outcomes.
12. Driving will be required to county offices.
13. Maintain confidentiality, HIPAA compliance, and knowledge of mandated reporting requirements.?
14. Uphold agency standards, policies, and procedures as outlined in the Employee Handbook.
15. Participate in departmental meetings and trainings as required.?
16. 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.