Eligibility Specialist/Care Coordinator

Job Description

Job Description

Summary:

The Eligibility Specialist / Care Coordinator is responsible for ensuring clients maintain active and eligible insurance coverage throughout their course of treatment while providing administrative care coordination support. This position plays a critical role in verifying insurance eligibility, monitoring benefit status, assisting clients with eligibility renewal requirements, and coordinating with county agencies, health plans, and referral sources to prevent interruptions in services. The Eligibility Specialist / Care Coordinator works collaboratively with clinical, admissions, and billing staff to ensure compliance with SAPC, DHCS, Drug Medi-Cal, and other payer requirements while supporting clients in maintaining access to medically necessary treatment.

Essential Duties and Responsibilities:

Including, but not limited to, the following described duties - reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.

• Verify and maintain client insurance eligibility and benefits throughout the duration of treatment.
• Monitor client eligibility status to ensure compliance with current SAPC, DHCS, Drug Medi-Cal, and health plan requirements, including the 2027 eligibility and enrollment standards.
• Proactively identify clients whose insurance or eligibility is at risk of lapsing and initiate appropriate follow-up.
• Assist clients with completing eligibility renewals, recertifications, and required documentation to maintain active insurance coverage.
• Coordinate with county agencies, managed care plans, Medi-Cal offices, and other entities to resolve eligibility issues and prevent interruptions in treatment.
• Verify insurance benefits, obtain authorizations when applicable, and communicate benefit information to clinical and administrative staff.
• Monitor insurance verification reports and maintain accurate records of eligibility status and benefit information.
• Educate clients regarding insurance requirements, renewal deadlines, and documentation needed to maintain eligibility.
• Collaborate with admissions, counselors, case managers, billing staff, and leadership to ensure clients remain financially and programmatically eligible for services.
• Document all eligibility verification activities, client contacts, and insurance updates in the electronic health record (EHR) and other required tracking systems.
• Maintain accurate tracking spreadsheets, reports, and documentation related to insurance eligibility and client enrollment.
• Assist clients with referrals to community resources when additional assistance is needed to maintain healthcare coverage.
• Maintain confidentiality of all client information in accordance with HIPAA and agency policies.
• Participate in team meetings, trainings, audits, and compliance reviews.
• Perform general administrative and care coordination duties as assigned.

Education:

• High school diploma or equivalent required.
• Associate degree in Healthcare Administration, Human Services, Social Work, Behavioral Health, Business Administration, or a related field preferred.

Certificates, Licenses, Registrations:

• Valid California Driver's License (or ability to obtain one) and current automobile insurance.
• Background check and TB clearance as required by program standards.
• CPR/First Aid certification preferred.

Professional Experience:

• Minimum of one (1) year of experience in healthcare eligibility, insurance verification, case management, care coordination, admissions, behavioral health, or a related field preferred.
• Experience verifying Medi-Cal, Drug Medi-Cal, commercial insurance, or managed care benefits preferred.
• Familiarity with SAPC, DHCS, Drug Medi-Cal Organized Delivery System (DMC-ODS), and health plan eligibility requirements preferred.
• Experience working with electronic health record (EHR) systems and insurance verification portals.
• Strong organizational, problem-solving, and time management skills with exceptional attention to detail.
• Excellent communication and customer service skills with the ability to work effectively with clients, families, insurance representatives, and community agencies.
• Ability to manage multiple priorities