In Home Eligibility Lead

Program Delivery Lead / IHWA In‑Home Eligibility Lead

The Program Delivery Lead strategically identifies, develops, and implements programs that influence providers, members or market leadership towards value‑based relationships and/or improved quality metrics. The Program Delivery Lead works on problems of diverse scope and complexity ranging from moderate to substantial. The IHWA In‑Home Eligibility Lead is responsible for overseeing and managing eligibility strategy, execution, and data integrity for in‑home Quality Focused Visit (QFV) and related IHWA vendor programs.

This role ensures accurate member targeting, consistent eligibility logic, and timely file delivery across multiple vendor partners, supporting high‑quality execution, Stars outcomes, and operational scalability.

• Develop and implement programs that influence providers, members, and market leadership towards value‑based relationships and improved quality metrics.
• Identify and solve problems ranging from moderate to substantial complexity.
• Oversee and manage eligibility strategy, execution, and data integrity for QFV and related IHWA vendor programs.
• Ensure accurate member targeting, consistent eligibility logic, and timely file delivery across multiple vendor partners.
• Collaborate closely with IHWA operations, Stars, analytics, IT, and external vendors.
• Design and maintain eligibility criteria, minimize overlap across in‑home programs, and resolve eligibility risks.
• Translate program and quality requirements into executable eligibility rules, data files, and automated processes.
• Analyze complex data, exercise sound judgment, and drive continuous improvement in eligibility processes.
• Support transition from manual processes to automated, scalable solutions.

• Bachelor’s degree in business, healthcare administration, public health, information systems, or a related field; equivalent experience considered.
• 5+ years of experience in healthcare operations, program delivery, eligibility management, or performance analytics.
• Demonstrated experience managing eligibility criteria and file delivery across multiple vendors or partners.
• Strong understanding of in‑home healthcare programs, quality initiatives, or Stars‑related workflows preferred.
• Proven ability to work with complex data sets, including eligibility files, member lists, and disposition data.
• Experience collaborating cross‑functionally with IT, analytics, operations, and vendor partners.
• Strong analytical and problem‑solving skills, with the ability to identify eligibility risks, inconsistencies, or gaps.
• Excellent communication skills, including the ability to explain complex eligibility logic to technical and non‑technical stakeholders.
• Ability to manage multiple priorities and deadlines in a fast‑paced, high‑visibility environment.
• Proficiency with SQL.
• Proficiency with data and reporting tools (e.g., Excel, SQL, Power BI, Tableau, or similar).

• Experience supporting Quality Focused Visits (QFV) or similar quality‑driven in‑home programs.
• Familiarity with Medicare Advantage, Stars measures, and member eligibility requirements.
• Experience designing or managing daily eligibility file processes and automation initiatives.
• Background in vendor governance, performance monitoring, or contract support.
• Experience defining eligibility logic, prioritization rules, and exclusion criteria to minimize overlap and operational risk.
• Knowledge of data governance, data quality controls, and audit readiness.
• Experience working with APIs or automated data exchanges with external partners.
• Master’s degree in healthcare administration, public health, data analytics, or a related field.

• Internet service of home or hybrid home/office employees must meet at least a download speed of 25
  
  Mbps and an upload speed of 10
  
  Mbps; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from home in California, Illinois, Montana, or South Dakota will receive a bi‑weekly payment for their internet expense.
• Home or hybrid home/office…