Participant Navigator

Description

The Participant Benefits Navigator reports directly to the Chief Financial Officer and works under the day-to-day operational direction of the Medical Management Coordinator. The role functions as a key liaison between Finance, Medical Management, Enrollment, and external agencies to support participant financial operations and Medicaid administration.

This position serves as the primary liaison between participants, the Finance Department, and external agencies regarding Medicaid eligibility, coverage, participant cost‑sharing, and related billing processes. The role is responsible for coordinating Medicaid enrollment and recertification, monitoring ongoing coverage, resolving payment and eligibility issues, and ensuring accurate participant billing and reimbursement. Working collaboratively across Finance, Medical Management, Enrollment, and Adult Day Services, this position helps maintain regulatory compliance while providing education, guidance, and exceptional customer service to participants and their families.

The position also supports financial operations through payment reconciliation, insurance coordination, reporting, and oversight of participant funding sources.

• Collaborates with the PACE Finance team to manage Medicaid‑related billing, coverage verification, and participant cost‑sharing requirements.
• Serves as the primary liaison between the Finance Department and other departments for issues related to participant payments and non‑payments.
• Reconciles Medicaid payments against participant enrollment records.
• Serves as the primary contact for participants and their representatives regarding cost‑sharing requirements, payment changes, and outstanding balances.
• Assists current PACE participants in determining Medicaid eligibility, completing applications, and submitting required documentation.
• Monitors Medicaid renewal deadlines to ensure participants maintain continuous coverage without lapses.
• Manages the Medicaid recertification process and serves as the process owner.
• Maintains current knowledge of Rhode Island Medicaid regulations and PACE‑specific eligibility requirements to ensure accurate application and renewal processing.
• Educates participants and their families regarding Medicaid benefits, rights, responsibilities, and the recertification process.
• Serves as the primary liaison between PACE and the Department of Human Services (DHS), Managed Care Organizations (MCOs), and other applicable agencies for Medicaid renewals. (Agency terminology to be confirmed.)
• Maintains accurate participant records, tracks Medicaid renewals, and prepares reports related to renewal activity and compliance.
• Works with participants and their families to resolve automatic disenrollments resulting from enrollment in another health plan or the Hospice Benefit by determining participant intent and assisting with cancellation of unintended enrollments.
• Completes participant address verification updates with the Social Security Administration and the Centers for Medicare & Medicaid Services (CMS).
• Reconciles participant over‑asset payments in accordance with Medicaid requirements.
• Ensures Adult Day Services invoices are prepared and submitted timely by providing Finance with accurate billing information.
• Coordinates the submission of Adult Day Center attendance records to applicable insurance carriers.
• Ensures discharge plans are established and that all required documentation is forwarded to receiving programs in a timely manner.
• Coordinates participant enrollment into the Adult Day Center program, ensuring all required documentation, consents, and enrollment paperwork are completed.
• Serves as a backup resource for alternate funding sources for both PACE participants and Adult Day Program attendees by verifying coverage and coordinating follow‑up with funding agencies.
• Develops and maintains collaborative relationships with participants, families, state agencies, managed care organizations, and community providers to support seamless transitions and ongoing participant services.
• Maintains current knowledge of enrollment policies, reimbursement methodologies, and state agency…