Healthcare Eligibility / Enrollment Specialist

V Group Inc.; California; On-site; USD 40,000 - 65,000; Full time

Job summary

An established industry player is looking for a motivated Healthcare Eligibility/Enrollment Specialist to join their team. This role involves providing specialized services for Medi-Cal eligible members, ensuring eligibility accuracy, and supporting customer service initiatives. You will assist with data reporting, analysis, and reconciliation, while also acting as a liaison between departments. If you have a passion for healthcare and customer service, this opportunity is perfect for you. Join a mission-driven culture focused on high-quality performance and make a difference in the lives of members.

Qualifications

• 1 year experience in eligibility and/or reconciliation required.
• Bilingual in English and one of CalOptima's threshold languages preferred.

Responsibilities

• Provide assistance with specialized services for Medi-Cal eligible members.
• Coordinate eligibility analysis and strategic provider assignments.
• Prepare reports and perform reconciliation procedures.

Skills

Customer Service

Data Analysis

Eligibility Monitoring

Bilingual Communication

Education

High School Diploma

Experience in Eligibility/Reconciliation

Tools

Excel

Access Database

Job description

Healthcare Eligibility / Enrollment Specialist

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For more details, please connect with Ibad Ullah Khan at 971-431-1753 or email at [e-mail]

Job Title: Healthcare Eligibility / Enrollment Specialist / Program Assistant

Duration: 06+ Months

Start Date: ASAP

Location: 505 City Parkway West, Orange CA 92868 (100% Onsite)

Position Type: Contract

Interview Type: In Person/Web Interview

Department: Department of Customer Service

Description:

• CalOptima Health is seeking a highly motivated and experienced Program Assistant (Enrollment - Medi-Cal) to join our team. The Program Assistant will provide assistance with specialized services for Medi-Cal eligible members, including data reporting, analysis, and reconciliation. The incumbent will be responsible for maintaining eligibility accuracy by monitoring, updating, and reviewing current Medi-Cal program requirements.

Duties & Responsibilities:

95% - Program Support

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Coordinates specialized processes, including eligibility analysis, strategic provider assignments, age restriction and complex condition member administration/monitoring, and floor audits for the Medi-Cal program.
• Assists with completing various member requests, such as Change of Health Network Requests, primary care provider (PCP) change requests, and data correction forms.
• Responds to questions and interprets policies and regulations.
• Prepares materials (e.g., letters/surveys) and coordinates data files for mail merge as applicable.
• Ensures processes are accurate and compliant with regulatory requirements by maintaining and documenting workflows, procedures, and policies.
• Represents the Medi-Cal program on projects or as a liaison within or outside CalOptima Health.
• Facilitates communication on specialized topics.
• Prepares reports and creates reporting tools; performs reconciliation procedures, including Excel sorts, filters, merging, and Access database procedures.
• Acts as liaison between the Enrollment department and other Customer Service staff.
• Supports quality assurance audits to validate the accuracy of PHI/AOR and Acceptance Letter updates processed by staff.
• Conducts outreach to members and insurance carriers to verify Other Health Coverage (OHC).
• Assists with processing member surveys by updating profiles with demographic, coverage, and address changes.

5% - Other

• Completes other projects and duties as assigned.

Minimum Qualifications:

• High school diploma or equivalent plus 1 year of experience in eligibility and/or reconciliation; an equivalent combination of education and experience may also qualify.

Preferred Qualifications:

• Experience with health insurance (Medi-Cal).
• Experience interacting with regulatory agencies such as DHCS and DMHC, related to Medi-Cal.
• Experience in HMO, managed care, or Medi-Cal settings.
• Customer Service experience.
• Bilingual in English and one of CalOptima's threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).