Eligibility Manager

Job Details

Level: Management

Job Location:

Fresno - Fresno, CA 93721

Position Type:
Full Time

Salary Range: $70,304.00 - $85,000.00 Salary/year

Job Shift: Day

Job Category:
Management

PACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant.

Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive.

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

The Eligibility Manager is responsible for leading and overseeing the Eligibility department within the Finance team for IIH PACE. This position is accountable for ensuring accurate and timely determination, maintenance, and optimization of participant eligibility and enrollment, which directly maximizes revenue and minimizes financial risk. The Eligibility Manager provides strategic direction, leadership, and supervision to the Eligibility Supervisor and Eligibility Specialists while ensuring full compliance with all state and federal regulations, including Medi-Cal and Medicare requirements.

This role requires close collaboration with multiple departments (Claims, Intake, Social Work, and others) to resolve complex eligibility issues and drive process improvements. Travel to other Innovative Integrated Health may be necessary on occasion for coverage needs and management oversight.

Duties include, but are not limited to:

• Provide leadership, supervision, and mentorship to the Eligibility Supervisor and all Eligibility Specialists, including performance management, training, and professional development.
• Responsible for performance management of departmental employees, including recognition, performance evaluations, formal coaching and counseling, and making decisions or recommendations regarding necessary disciplinary actions.
• Oversee daily operations of the Eligibility team to ensure timely and accurate processing of participant enrollments, disenrollments, and eligibility determinations.
• Ensure compliance with all Medi-Cal, Medicare, and PACE eligibility and enrollment regulations, including ongoing monitoring of regulatory updates from DHCS, CMS, and other agencies.
• Oversee the review and reconciliation of 820/834 files, Daily Transaction Reply Reports (DTRRs), and other eligibility transaction files.
• Develop, implement, and continuously improve policies, procedures, and workflows related to eligibility determination, retrospective/prospective enrollments, disenrollments, Share of Cost (SOC), out-of-area issues, and excluded benefits.
• Serve as the primary point of escalation for complex eligibility and enrollment issues, working collaboratively with Intake, Social Work, Claims, and other departments to achieve timely resolutions.
• Manage internal and external eligibility verification processes, including responses to CMS review packages and audits via Electronic Retroactive Processing Transmission.
• Analyze eligibility-related accounts receivable, identify trends and opportunities for revenue optimization, and implement corrective action plans
• Prepare regular reports and dashboards on eligibility metrics, team performance, and compliance for the Director of Finance and senior leadership.
• Lead or participate in cross-functional projects, committees, and initiatives aimed at improving participant experience and operational efficiency.
• Maintain expert-level knowledge of PACE, Medi-Cal, and Medicare eligibility rules and serve as the subject matter expert for the organization.
• Attend and actively participate in staff…