PACE Eligibility Navigator

San Ysidro Health; San Diego, Northern (CA, KY); Hybrid; USD 60,000 - 80,000; Full time

Job summary

San Ysidro Health is seeking a PACE Eligibility Navigator to support enrollment and retention for San Diego PACE participants. You will verify Medi-Cal and Medicare eligibility accurately and timely, collaborating with internal teams, participants and state agencies.

Responsibilities include completing renewal packages, facilitating enrollments, and maintaining data integrity across SD PACE systems. The role requires knowledge of public health guidelines and strong communication skills in a

Qualifications

• 2+ years of Medi-Cal/Medicare eligibility coordination experience.

Responsibilities

• Initiates and monitors health coverage renewal processes.
• Assists individuals in applying for/retaining health coverage.
• Complete and submit health coverage applications and follow up with agencies.
• Review Medicare eligibility monthly and identify issues.
• Process enrollment/re-enrollment through CMS portal.

Skills

Medi-Cal eligibility

Medicare eligibility

DHCS guidelines

CMS guidelines

Bilingual English/Spanish

Education

High School Diploma or GED

Bachelor’s degree in health/human services

CA driver’s license with insurance

Tools

EPIC

Quick Cap

Apptivo

DHCS Provider Portal

Benefits Cal

CMS

Availity

Job description

Position Summary:

Under the supervision of the PACE Eligibility Supervisor, the PACE Eligibility Navigator supports the enrollment and retention of participants in San Diego PACE by ensuring accurate and timely verification of Medi-Cal and Medicare eligibility. This position works collaboratively with internal departments, external partners, PACE participants and their family members and state agencies to resolve PACE participant eligibility issues. Assist with new and retroactive enrollments to ensure participants can gain or maintain coverage. The navigator serves as a subject matter expert in state and federal health coverage guidelines and plays a key role in maintaining compliance and data integrity.

Essential Functions of the Job:

• Initiates and monitors health coverage redetermination/renewal process for patients. Completes Medi-Cal Renewal Package. Reports on all changes in active accounts, Medi-Cal Add-Ons, Referrals.
• Assists individuals in applying for and retaining health coverage by collecting necessary and accurate personal and demographic information; conducting home, daycare, or facility visits to determine eligibility; assessing needs; providing accurate information about health coverage options; uploading and submitting verification documents.
• Complete and submit health coverage applications. Initiate and maintain proper follow-up with patient and government agency to ensure timely processing and completion of all mandated applications and accompanying documentation.
• Review participants' Medicare eligibility monthly to identify any issues that may result in the SD PACE plan's Medicare non-assignment.
• Initiate the process and complete the enrollment / re-enrollment transaction packet through the CMS portal for new and current Medicare participants. Reports on the changes to claims department and documents changes in multiple SD PACE systems.
• Track and report eligibility issues including inactivity Medicaid, aid code discrepancies, IHSS involvement, and managed care plan assignments for Medicaid and Medicare including demographic discrepancies, and hospice status.
• Review’S Share of cost (SOC) monthly for participants and reports any changes to the Finance Department, completes and submits required reports SD PACE. Generate participant eligibility notices and track follow-up actions.
• Prepare and submit retroactive enrollment and disenrollment requests per DHCS guidelines and CMS guidelines.
• Create and submit monthly reports related to Medi-Cal eligibility. Maintains records on active PACE census, tracks dis-enrollments for proper reporting to DHCS/CMS.
• Conducts the MSP survey (Medicare as Secondary) within 30 days of enrollment for new participants and reviews MSP monthly via multiple systems.
• Ensures all patient demographic systems are updated to ensure accuracy of participant eligibility status.
• Prepares patient/client correspondence as needed. Maintains accurate and thorough records of all communications with participant/family members on EMR.
• Collaborate with enrollment, social services, transition of care, referral, and finance teams to align eligibility with enrollment and claims deadlines.
• Work with claims department to address Medi-Cal and Medicare encounter rejections related to eligibility and demographic information.
• Conducts clinic in-reach and education activities, individually and in groups, to SD PACE participants and community members at PACE locations and other community locations about PACE services and program eligibility updates.
• Supports Enrollment Department Team with on-site training for new staff when requested.
• Develop positive relationships with the San Diego County Medi-Cal and Social Security Administration staff and the Department of Health Care Services staff.
• Facilitates referral to SD PACE and community resources for assistance with other needs and intricate issues.

Additional Duties and Responsibilities:

• Complies with all departments, organizational, and government policies and procedures.
• Attend meetings and training courses as required.
• Performs other related duties as assigned or requested.

Education Required:

• High School Diploma or GED equivalent or relevant experience.

Education Preferred:

• Bachelor’s degree in a health or human service field.

Certifications/Licenses:

• CA driver’s license with appropriate automobile insurance required.
• The Financial Health Plan Navigator must complete the State of California DHCS PACE and Medi-Cal Marketing training within 60 days of hire.
• Certified Enrollment Counselor (CEC) exam and SYH Eligibility Competency Exam within the 90-day probationary period.

Experience:

• 2+ years of experience in Medi-Cal, Medicare, or health plan eligibility coordination.
• Strong knowledge of health plan systems, state MEDICAID aid codes, and DHCS and CMS guidelines.
• Excellent communication and customer service skills.

Verbal and Written Skills to Perform the Job:

• Must have excellent oral and written communication skills.
• Bilingual (English/Spanish) is preferred but not required.

Technical Knowledge and Skills to Perform the Job:

• Knowledge of local, state, and federal public health assistance programs and respective policies and regulations.
• Proficient in Microsoft applications and use of electronic health data systems including EPIC, Quick Cap, Apptivo, DHCS Provider Portal, Benefits Cal, CMS, Availity.
• At a minimum, have good computer/tablet literacy including internet navigation and research skill.

Competencies:

Demonstrated ability to be culturally sensitive and respect diversity.

Collaborate effectively with individuals of diverse cultures and socio-economic status.

Passion for service; initiative-taker and highly organized; ability to prioritize and complete a large volume of work within strict time deadlines.

Provide prompt, efficient, and responsive customer service.

Demonstrated critical thinking skills, and consistent use of analytical and problem-solving skills.

Detail oriented with strong time management and organizational skills.

Equipment Used:

Computers, iPads/tablets, phones, personal vehicle, copy machines, fax machines, and other general office equipment.

Working Conditions and Physical Requirements:

• May be required to lift to 30 lbs.
• Will be required to travel to other sites or other locations within San Diego County.

Universal Requirements:

Pre employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.