Eligibility Manager

Eligibility Manager Fully Remote • Fresno - Fresno, CA 93721 Apply Overview Salary Range $70,304.00 - $85,000.00 Salary/year Level Management Position Type Full Time Job Shift Day Category Management Apply Description Who We Are 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. Benefits 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 Job Summary 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. Essential Job Functions 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 meetings, in-services, and required training. Adhere to and promote company policies, procedures, and core values. Accept assigned duties in a cooperative manner; and perform all other related duties as assigned. Be flexible in schedule of hours worked. May be required to use a personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required. Qualifications Knowledge, Skills and Abilities Strong leadership and people management skills with the ability to motivate, develop, and hold team members accountable. Expert knowledge of Medi-Cal, Medicare, and PACE eligibility and enrollment requirements. Proficient in Microsoft Office (Word, Excel, PowerPoint, Outlook) and ability to quickly learn organizational systems. Excellent analytical, problem-solving, and critical thinking skills. Superior verbal and written communication skills. High level of attention to detail combined with strong organizational and time management abilities. Ability to manage multiple priorities in a fast-paced environment and adapt to changing regulations. Demonstrated ability to work independently and collaboratively across departments. Strong understanding of revenue cycle processes as they relate to eligibility and enrollment. Working Conditions and Physical Demands The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to access all areas of the center throughout the workday. Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee when attempting to lift or transfer objects over 50 pounds. Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling. Ability to communicate verbally with an excellent comprehension of the English language. Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment. May require use of personal vehicle for business-related travel. Experience Minimum of five (5) years of progressive experience in eligibility, enrollment, or revenue cycle management within a managed care organization required, preferably in a PACE or senior care setting. Minimum of three (3) years of supervisory or managerial experience required. In-depth knowledge of Medi-Cal and Medicare regulations strongly preferred. Education and Certification Bachelor’s degree in Business Administration, Healthcare Administration, or related field required Master’s Degree preferred. Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact. Core Values CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants. COMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care. CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow. COMMUNITY that fosters connection, belonging, and support for participants and their families. COMMITMENT to quality improvement, innovation, and delivering healthier outcomes. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.