PACE Enrollment Specialist

Position Title:

PACE Enrollment Specialist Department: PACEHours per week: 40 (8:30 AM–5:00 PM, with a 30-minute unpaid lunch (8 hours paid).Primary Function:

The PACE Enrollment Specialist supports prospective and current PACE participants with Mass Health and Medicare eligibility, applications, renewals, verifications, and ongoing enrollment requirements. The Specialist serves as a primary guide for participants, families, and caregivers navigating complex public benefits, particularly for dually eligible individuals (Medicare & Mass Health). Key responsibilities include reviewing documentation, monitoring application status, resolving coverage barriers, and ensuring a seamless transition into PACE.The

Specialist is an integral member of the Intake & Enrollment team, collaborating closely with the Interdisciplinary Team (IDT), the Insurance/Billing Department, CMS, Mass Health, and external partner agencies to ensure all eligibility, payer source, and regulatory requirements are fulfilled accurately and on schedule.

Duties & Responsibilities:

Medicare & Mass Health Eligibility Navigation Explain Mass Health and Medicare eligibility requirements, PACE covered benefits, and rules to prospective and current participants, families, and caregivers.

Conduct preliminary eligibility reviews, including income, assets, Medicare Parts A, B, and D status, supplemental insurance, and other applicable payer requirements.

Educate prospective enrollees on how PACE integrates Medicare and Medicaid benefits into a single comprehensive model, including the requirement to receive all primary, specialty, and prescription drug care through the PACE network.

Identify potential eligibility barriers, spend-downs, or coverage discrepancies and coordinate resolution with appropriate team members.

Serve as an internal subject matter resource on Mass Health and Medicare eligibility.

Compliance & Quality Prepare Written Notices & Determination Letters:
Draft, finalize, and issue timely written notification letters for prospective participants who do not meet clinical, geographic, or financial eligibility criteria (denial of enrollment), as well as required notices for participants facing involuntary disenrollment (e.g., loss of Mass Health eligibility, relocation outside service area, failure to pay cost share, disruptive behavior/safety reasons) in accordance with CMS regulations, Mass Health rules, and organizational policies, ensuring proper inclusion of grievance and appeal/fair hearing rights.

Audit Preparation & Support:
Participate in CMS and Mass Health audits, regulatory site visits, and state oversight reviews, including preparing documentation, participant files, and enrollment logs.

Quality Improvement:
Participate in continuous quality improvement initiatives regarding Intake & Enrollment processes, application cycle times, conversion rates, and retention workflows.

Regulatory Adherence:
Maintain confidentiality and strict adherence to HIPAA, CMS marketing guidelines, Mass Health contractual obligations, and culturally competent care standards.

General:
Perform other duties as assigned.

Intake & Enrollment Support Facilitate communication among participants, families, caregivers, and the Interdisciplinary Team (IDT).Provide relevant participant information and documentation to support IDT review, transition, and care planning for new enrollees.

Maintain tracking systems for enrollment activities, reassessments, eligibility requirements, and regulatory deadlines.

Minimum Basic Knowledge:

Familiarity with Mass Health applications, renewals, redeterminations, and eligibility verification processes.

Understanding of PACE enrollment requirements and how Mass Health eligibility impacts PACE enrollment and continued…