Eligibility Representative II

We are so glad you are interested in joining Sutter Health!

Organization:

SSC-Sutter Senior Care

Position Overview:

The Eligibility Specialist is responsible for supporting the accurate determination, verification, maintenance, and reinstatement of participant eligibility and enrollment in the Program of All-Inclusive Care for the Elderly (PACE). This role focuses on monitoring and coordinating Medicare and Medi-Cal eligibility, managing annual redetermination, coordination of benefits (COB), retroactive enrollments/reinstatements, and resolving eligibility-related accounts receivable issues. The specialist ensures compliance with state and federal regulations while contributing to the financial and operational goals of the PACE program.

The Eligibility Specialist works collaboratively with the Intake, Social Work, Claims, Pharmacy, and Interdisciplinary Team to facilitate timely enrollment, redetermination, reinstatements, and COB processes, while providing participant-centered care for frail elderly individuals in the PACE program.

Analyzes monthly eligibility activity reports, reconciles current member lives reported by CMS and DHCS. Assigns and maintains monthly membership lives appropriately. Accurately updates, maintains, and retrieves eligibility information within Sutter Health's database.

Job Description:

EDUCATION:

• HS Diploma or General Education Diploma (GED)
• Associate Degree or Bachelors degree preferred

TYPICAL EXPERIENCE:

• 1 year of recent relevant experience.
• Minimum of two (2) years of professional experience in a managed care organization, healthcare eligibility, enrollment, or coordination of benefits role required or in lieu of experience, an Associate’s Degree.
• Experience with Medicare and/or Medi-Cal eligibility, redetermination, and PACE processes strongly preferred.
• Familiarity with DHCS and CMS systems (834 files, DTTRs, MARx) is a plus.
• Minimum of one (1) year of documented experience working with a frail or elderly population.

Duties include, but are not limited to:
 

• Eligibility Monitoring and Verification:
  • Monitor and track daily participant eligibility and enrollment status as reported by the Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS).
  • Review and reconcile 820/834 eligibility and payment files from DHCS and Daily Transaction Reply Reports (DTRRs) from CMS.
  • Track Medicare entitlement dates and work closely with the Intake team to ensure timely and accurate enrollment into the PACE program.
• Medi-Cal Redetermination Assistance
  • Track upcoming Medi-Cal annual redeterminations (financial, categorical, and residency) at least 120 days in advance using DHCS 834 reports, MEDS data, and internal records.
  • Conduct outreach (phone, mail, in-person, text) and document consent for assistance using authorized representative forms (e.g., MC382/MC383).
  • Occasionally assist the Patient Advocate and participants/representatives with gathering verifications, completing forms, and submitting renewals to the county (via portal, mail, or e-fax) during the process and 90-day cure period.
  • Follow up on status, assist with appeals or reapplications if needed, and notify IDT of any potential coverage gaps.
  • Maintain data files in Excel for tracking and reporting.
• Reinstatement and Retroactive Enrollment Support
  • Identify cases of accidental enrollment in another Medi-Cal or Medicare plan and Medi-Cal-only participants turning 65.
  • Occasionally perform outreach, obtain consent, and gather required documentation (signed Enrollment Agreement, IDT assessments, eligibility verifications).
  • Coordinate disenrollment from other plans and prepare/submit retroactive requests to the CMS Retroactive Processing Contractor (RPC) within 90 days (or escalate older cases).
  • Submit DHCS Enrollment/Disenrollment Request Logs per policy letters.
  • Align dates for age-related Medicare entitlement transitions and ensure seamless PACE coverage.
  • Maintain the data files in Excel and report outcomes to leadership.
• Enrollment, Disenrollment, and Cross-Departmental Support:
  • Update and maintain enrollment/eligibility databases, tracking spreadsheets, and participant records.
  • Assist all departments in confirming and verifying participant eligibility for internal use and external inquiries (providers, CMS, DHCS).
  • Collaborate with Intake, Social Work, Claims, and Pharmacy teams to resolve eligibility, redetermination, reinstatement, and COB barriers. Communicate resolutions clearly and supportively to participants and families.
• Compliance and Team Collaboration:
  • Maintain current knowledge of PACE eligibility, enrollment, redetermination, reinstatement, retroactive processing, and COB requirements under CMS (42 CFR Part 460) and DHCS regulations
  • Occasional travel to participants’ homes, PACE centers, or county offices may be required for outreach, redetermination assistance, eligibility coordination, or other job-related duties. Attend and actively participate in staff meetings, in-services, quality improvement projects, and assigned committees.
  • Adhere to all center policies, procedures, and HIPAA/privacy requirements.
  • May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required.

SKILLS AND KNOWLEDGE:

• Proficient in MS Office (Word, Excel, Access, PowerPoint, Outlook) with strong Excel skills for tracking logs and reporting.
• Knowledge of general office procedures, equipment, and filing systems.
• Effective oral and written communication skills, including the ability to interact professionally with participants, families, and internal/external stakeholders.
• Strong attention to detail, accuracy, and organizational skills with the ability to manage multiple priorities.
• Knowledge of Medi-Cal and Medicare eligibility rules, aid codes, Share of Cost, PACE enrollment, redetermination, reinstatement, retroactive processes, and COB requirements.
• Ability to work independently with minimal supervision while functioning as part of a collaborative team.
• Commitment to participant-centered care and the PACE model of supporting frail elders to remain independent in the community.

Customer service communication and proper telephone etiquette skills.

Knowledge of capitation methodology.

Knowledge of Managed Care processes.

Computer and intermediate data entry at 45 WPM.

Analytical skills in abstracting and compiling enrollment and capitation data using Access and Excel programs.

Must be detail oriented and have written and verbal skills.

Skills in data collection techniques and record keeping, demonstrating attention to detail and consistent follow through.

Basic math skills.

Ability to work independently with minimal direction.

Operate basic office equipment such as copy machines, fax machines, computers, etc.

Ability to work as a team member to meet contractual deadlines.

Effective time management skills.

Understanding of a variety of membership processing procedures for various health plans.

Knowledge of Health Plan Utilization processes, such as third-party payer regulations and compliance policies.

Knowledge of medical terminology.

 

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

None

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $29.52 to $41.33 / hour

The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.