Eligibility Navigator - PACE

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The Brandman Centers for Senior Care (BCSC), a Program of All-inclusive Care for the Elderly (PACE), provides high-quality, comprehensive healthcare services. We are a program of Los Angeles Jewish Health, renowned for providing quality care to vulnerable seniors.

Under the supervision of the Brandman Centers for Senior Care (BCSC) PACE Manager of Health Plan Operations, the Eligibility Navigator plays a key role in supporting the daily operations of the Health Plan department, ensuring accurate and timely management of Medi-Cal and Medicare eligibility, enrollment, and related processes for program participants.

Administrative Functions

• Manage daily Medi-Cal and Medicare eligibility verification, enrollment, and disenrollment processes for participants.
• Develop, maintain, and refine tracking systems for all eligibility and enrollment workflows.
• Coordinate with County, State, and Federal agencies (e.g., DPSS, DHCS, Social Security Administration) to confirm, update, and reconcile participant eligibility data.
• Support pre-enrollment verification and resolve discrepancies to ensure continuity of benefits.
• Track and facilitate the Medi-Cal redetermination process, working collaboratively with Social Workers and County representatives to prevent coverage interruptions.
• Oversee and resolve eligibility issues related to Medicare Part D (PDP) operations, including TROOP, PDE, and RAPS rejections.
• Provide direct participant support and education regarding eligibility, coverage status, and renewal processes.
• Manage age-in transitions for participants newly eligible for Medicare.
• Reconcile enrollment data monthly, ensuring accuracy across internal systems, capitation files, and vendor partner rosters.
• Maintain compliance with DHCS submission and reporting requirements for enrollments and dis-enrollments.
• Monitor internal authorization workflows to ensure timely completion and perform retro-reviews for unauthorized services identified by the third-party administrator (TPA).
• Support audit preparation, documentation, and corrective action tracking related to Health Plan oversight activities.
• Oversee participant materials fulfillment (e.g. ID card requests, ADA-compliant materials, and regulatory notices).
• Manage ongoing Medicare Part D regulatory reporting and compliance tracking.
• Collaborate with the Finance department and TPA on self-pay billing activities and participant accounts.
• Ensure accurate processing of enrollment-related financial transactions and reconciliation of premium and capitation data.
• Participate in quality assurance initiatives to improve operational efficiency and participant experience.
• Perform other related duties and special projects as assigned.
• Completes other duties as assigned.

Education and Experience

• Degree and diplomas: Associate’s degree or equivalent experience in healthcare, business, or a related field required.
• Experience: Minimum of 3 years of experience in health plan operations, eligibility coordination, or related functions within PACE, Medicare Advantage, Medi-Cal, or Medi-Medi plans preferred. Strong familiarity with Los Angeles County Medi-Cal eligibility systems and DPSS operations preferred. Experience in regulatory environments involving DHCS, CMS, or other health plan compliance bodies highly desirable.
• Skills/Aptitudes: In-depth understanding of health plan operations, enrollment and eligibility processes, and related compliance requirements. Demonstrated ability to navigate complex eligibility systems and resolve discrepancies accurately and efficiently. Excellent organizational, analytical, and problem-solving skills with strong attention to detail. High degree of professionalism and customer service orientation in participant interactions. Ability to work collaboratively across multidisciplinary teams and manage competing priorities in a fast-paced environment. Proficiency in Microsoft Office Suite, especially Excel; experience with electronic health record (EHR) or enrollment systems preferred. Spanish language, preferred.
• Core Attributes: Mission-driven commitment to serving frail and high-risk older adults. Strong sense of accountability and ownership of work outcomes. Effective communicator with empathy, discretion, and respect for participant confidentiality. Adaptable and proactive in an evolving healthcare environment.

Join Los Angeles Jewish Health and make a meaningful impact in the lives of seniors in our community. Become part of our compassionate team, dedicated to providing exceptional care and support. Apply today and start making a difference!