Eligibility Specialist

Job Title - Eligibility Specialist
Location – Remote - Fresno, CA
Duration - 6+ Months (Possible Extension)

Pay Range: $25 - $27 per hour. on W2

Job Summary:
The Eligibility Specialist is responsible for using their eligibility expertise to proactively address complex eligibility challenges and ensure seamless participant coverage. As a subject matter expert in Medicare or Medicaid Eligibility, the Specialist oversees resolution of escalated or complex eligibility cases. This position works directly with CMS, DHCS, and county Medicaid offices to troubleshoot eligibility issues, correct misalignments, and advocate for participants’ eligibility for the PACE program. This role also plays a key part in training internal teams, including Outreach & Enrollment and Social Work, to enhance organizational knowledge and prevent eligibility-related disruptions. The Eligibility Specialist collaborates effectively with colleagues and stakeholders to promote Client values, team culture and mission.

Job Responsibilities:

• Act as the organizational expert in Medicare or Medicaid eligibility policies and keep teams informed of regulatory updates.
• Provide guidance to leadership, internal teams, and stakeholders on eligibility cases, processes, and compliance requirements.

Duties:

• Oversee resolution of complex eligibility issues, including coverage misalignments, retroactive enrollments, reinstatements, and eligibility corrections.
• Work directly with CMS, DHCS, and county agencies to troubleshoot eligibility discrepancies and secure accurate benefit assignments.
• Advocate for participants in disputed eligibility cases to minimize gaps in coverage.
• Develop and deliver training programs for internal teams to improve eligibility accuracy and efficiency.
• Maintain knowledge repositories, job aids, and process documentation to support staff in handling eligibility cases.
• Monitor and analyze enrollment and eligibility data (e.g., DTRR, 834, 820, MMR) to identify trends, discrepancies, and risks.
• Must be willing and have the ability to work a varied schedule that may include evening nights, weekends and overtime.
• Complete all required documentation in a timely and accurate manner.
• Protect privacy and maintain confidentiality of all company procedures and information about team members, participants, and families.
• Follow Client policies and procedures and participate in any required Quality Improvement activities, staff training and meetings.
• Communicate regularly with Supervisor and team regarding workload and priorities.
• Timely completion of all mandated training and education.
• Timely completion of all mandated occupational health screenings as needed.
• Exercises flexibility in performing assignments as business needs evolve.
• Other duties as assigned.