Eligibility Specialist

St. Paul's PACE Corp, 3444 Camino Del Rio North, SAN DIEGO, California, United States of America

Posted Thursday, February 26, 2026 at 11:00 AM

San Diego’s St. Paul's PACE program (Program of All-Inclusive Care for the Elderly). This innovative program is for individuals 55 years or older, who are living with chronic illness, or disabilities and need coordinated medical care to continue living as independently as possible in their home and community. The healthcare teams l’s PACE provide a hands-on approach coordinating medical, social, and home care services so individuals no longer need to manage their medical care alone.

Job Summary: Under the supervision of the Director of Health Plan Operations, the PACE Eligibility Specialist assists current PACE participants in obtaining and maintaining Medi-Cal/Medicaid and Medicare coverage, across all PACE facilities and programs, ensuring continuous eligibility so they can access PACE services. This role involves working in a call‑center setting, verifying participant/member insurance coverage, authorizations, benefits, and eligibility, assisting both providers and participants with all Health Plan related inquiries.

This role will provide participant and family education, benefits counseling, and available applicable resources as necessary. This role also includes assisting with Medicaid Redeterminations and monitoring eligibility status to prevent lapses in coverage. As assigned, the Eligibility Specialist will connect with the other PACE teams to receive individualized case information, recommended approaches, care plan clarification, specific eligibility and application needs.

• Handle High-Volume Inbound Calls: respond to inquiries from both participants and providers regarding eligibility status, billing issues, and other Health Plan related questions.
• Provide authorization assistance to contracted vendors for upcoming scheduled visits or emergency cases.
• Assist individuals applying for or retaining Medi-Cal/Medicaid and Medicare coverage.
• Assists participants with address changes with Medi-Cal and Medicare.
• Maintain familiarity with local family resource centers.
• Assists participants and staff with disenrollment, follow-up documentation and insurance transition.
• Stay Current with Program Regulations:
  Participate in training and updates to ensure accurate information is communicated during calls.
• Explain eligibility requirements, benefits, and coverage options to participants and families.
• Identify and resolve enrollment-related issues (e.g., hospice flags, out-of-area situations, accidental disenrollments, retroactive eligibility).
• Assist with resolving problems related to benefits, documentation, or eligibility barriers.
• Acts as liaison and advocate for participant, caregivers and community agencies regarding participant benefits.
• Collaborate with Social Workers, Billing Specialists, Intake, and other PACE team members to resolve eligibility issues.
• Work with state agencies to resolve Medi-Cal issues including over-resources or documentation problems.
• Submit and track applications, renewals, and required documentation in accordance with DHCS, CMS, and county timelines.
• Conduct Phone-Based and Home Visit Interviews as needed to collect and verify financial, demographic, and household information required for eligibility determination.
• Assist participants at external offices when necessary (county social services, DMV, Social Security, banks, etc.).
• Educate staff, participants, and families regarding eligibility processes and updates.
• Provides ongoing support and education to participants and family regarding a variety of issues, including but not limited to: PACE model and PACE eligibility criteria.
• Support orientation and training for new team members and cross-functional teams, as needed.
• Write up and maintain standard operating procedures (SOP) for all processes.
• Follows all St. Paul’s PACE Policies and Procedures and OSHA safety guidelines.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
• Other duties as assigned.