PACE Eligibility Navigator

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.

• 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…