Eligibility Specialist

Job Brief

The Eligibility Specialist supports the review and coordination of eligibility determinations for individuals applying for services through the Office for People with Developmental Disabilities.

Shift Worked:


9AM-5PM

Weekly Hours:


37.5

FLSA Status:


Exempt

Pay range:


$25-$28

Position Summary:

The Eligibility Specialist supports the review and coordination of eligibility determinations for individuals applying for services through the Office for People with Developmental Disabilities. This role ensures that all eligibility determinations meet OPWDD criteria for Developmental Disability eligibility.


Key Responsibilities:

• Review and process eligibility applications in accordance with OPWDD guidelines for DD eligibility .
• Ensure required documentation is complete, accurate, and current, including:
  1. Internal forms
  2. SART
  3. Waiver approval
  4. Personal Documents
• Verify that eligibility criteria are met, including:
  1. Medicaid Exceptions Codes
  2. CCO Enrollment when applicable
• Review Level of Care (LOC) determinations to confirm need for ICF/IID level of services .
• Coordinate with Manger and Director obtain missing or updated documentation from Program.
• Track application status and ensure timely submission to OPWDD, HRA and other state and city entities for determination.
• Maintain organized and audit-ready eligibility filed in compliance with Medicaid and OPWDD requirements.
• Conduct internal quality reviews to ensure eligibility determinations are appropriate.
• Assist with outside entities related audits by ensuring documentation supports eligibility and service authorization.
• Identify discrepancies, insufficient documentation, or compliance risks and escalate as needed.
• Enter and maintain accurate data in Billing and EMR platforms.

Qualifications

• Bachelor's degree in accounting or related field.
• 1-3 years of experience in OPWDD eligibility, intake or case management.
• Strong knowledge of:
  1. OPWDD DD eligibility criteria
  2. Level of Care (LOC) / ICF-IID eligibility standards
• The Eligibility Specialist plays a critical role in ensuring that all eligibility determinations meet OPWDD standards for Developmental Disability and Level of Care and are fully supported by appropriate documentation. The Eligibility Specialist supports internal controls that align with Medicaid program integrity requirements andOffice of the Medicaid Inspector Generalexpectations, including documentation accuracy, verification, and audit readiness.

Skills & Competencies

• Strong analytical skills in reviewing eligibility documentation.
• Diligence and ability to identify missing or non-compliant records.
• Knowledge of OPWDD eligibility workflows and submission processes.
• Effective communication with interdisciplinary teams and external entities.
• Time management and ability to manage multiple cases simultaneously.

Work Environment

• Temporary position (3-6 months, may be extended based on operational need)
• Office-based/In-Person
• Interaction with internal departments and outside entities such as OPWDD, HRA, SNAP & SSA offices.