Eligibility Specialist

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 relevant agencies 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 to enhance organizational knowledge and prevent eligibility-related disruptions. The Eligibility Specialist collaborates effectively with colleagues and stakeholders to promote organizational 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.
• Oversee resolution of complex eligibility issues, including coverage misalignments, retroactive enrollments, reinstatements, and eligibility corrections.
• Work directly with relevant 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 to identify trends, discrepancies, and risks.
• Must be willing and have the ability to work a varied schedule that may include evenings, 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 company 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.

Required Skills & Experience

• Minimum of three (3) years of experience in Medicaid, Medicare eligibility, or social services.
• Minimum of one (1) year of experience in working with governmental agencies.
• Experience leading in a data-driven organization, leveraging reports and data to prioritize and manage people and projects.
• Experience and competency working with people from diverse backgrounds and cultures.
• Ability to process accurate information in a timely manner.
• Excellent leadership, organizational and communication skills in settings with seniors, their families, and interdisciplinary team members.
• Highly motivated, inspirational leader who is able to innovatively engage, support, and remove barriers for the team to ensure the team consistently meets established goals.
• Ability to work independently with minimal supervision.
• Demonstrated ability to prioritize in a fast-paced environment.
• Commitment to unlocking the full potential of our most vulnerable seniors.

Required Education

• Associate Degree in relevant field such as Business, Finance, or Healthcare related including Healthcare Administration, Medicare/Medicaid Policy, Human Services, or Social Services OR three (3) years of healthcare experience may be substituted.

Schedule

M-F 8a-4:30p, remote. Must have current experience with Medicare/Medicaid and spreadsheet-based work.