The Eligibility Supervisor reports directly to the Director of Health Plan Operations and is responsible for leading the daily operations of the Eligibility team, ensuring accurate, timely, and compliant processing of Medicare, Medi-Cal, and PACE eligibility, enrollment, disenrollment, and maintenance activities. This role oversees Eligibility Analysts while serving as the operational liaison between internal departments, external agencies, and regulatory partners. The Supervisor ensures compliance with CMS, DHCS, and myPlace Health policies while driving operational excellence, issue resolution, reporting, and continuous process improvement.
RESPONSIBILITIES:- Supervise the daily operations of the Eligibility department, ensuring Medicare, Medi-Cal, and PACE eligibility, enrollment, disenrollment, retroactive eligibility, and maintenance activities are completed accurately, timely, and in compliance with regulatory requirements
- Provide direction, coaching, development, and accountability for Eligibility staff; establish performance expectations and monitor productivity, quality, service levels, and operational outcomes.
- Ensure compliance with CMS, DHCS, HIPAA, and organizational requirements related to eligibility, enrollment, participant records, confidentiality, and regulatory reporting.
- Oversee Medicare eligibility and enrollment activities, including MARx transactions, enrollment reconciliation, Enrollment Validation audits, Retroactive Processing Center requests, Medicare Age-In activities, and related issue resolution.
- Oversee Medi-Cal eligibility verification, annual redeterminations, retroactive eligibility, and coordination with county eligibility offices, social workers, participants, and other external partners.
- Monitor eligibility work queues, review eligibility files and enrollment transactions, resolve escalated eligibility discrepancies, and coordinate corrective actions to maintain accurate participant records.
- Collaborate with Enrollment, Clinical Operations, Finance, Claims, Provider Operations, Compliance, Social Security, county agencies, and regulatory partners to support timely enrollment and resolve eligibility-related issues.
- Develop and maintain eligibility tracking tools, dashboards, and operational reports; analyze performance data, identify trends and root causes, and communicate findings to appropriate stakeholders.
- Develop and maintain eligibility policies, procedures, workflows, job aids, and training materials; implement process improvements that increase efficiency, accuracy, compliance, and participant satisfaction.
- Lead departmental preparation for internal and external audits by gathering documentation, researching eligibility records, responding to findings, and implementing or monitoring corrective actions.
- We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
- Actively support the achievement of myPlace's Vision and Goals.
- All other duties as assigned.
QUALIFICATIONS & EXPERIENCE:- Minimum of five years of experience in Medicare, Medi-Cal, Medicaid, managed care, PACE, or health plan eligibility operations.
- Minimum of two years of experience leading or supervising eligibility, enrollment, or health plan operations staff.
- Strong knowledge of Medicare, Medi-Cal, and PACE enrollment and eligibility regulations, including CMS and DHCS requirements.
- Experience with MARx, CMS enrollment processes, retroactive eligibility, and enrollment reconciliation.
- Demonstrated ability to manage competing priorities, resolve complex eligibility issues, and improve operational workflows.
- Strong written and verbal communication skills.
- Ability to collaborate effectively across departments, external agencies, and regulatory partners.
- Bachelor's degree in Business Administration, Healthcare Administration, Public Health, or a related field; an equivalent combination of education and experience may be considered.
Experience Preferred:
- 2-3 years of related experience
- 0-1 years of leadership experience
- Experience working in a PACE organization or Medicare Advantage plan.
- Experience with Athena, QuickCap, VisibilEDI, and eligibility file integrations.
- Experience with CMS Retroactive Processing Center requests, Medicare Part D enrollment operations, PDE, and RAPS issue resolution.
- Experience developing operational dashboards and reports using Excel, Power BI, or similar reporting tools.
- Experience supporting audits, corrective action plans, and regulatory compliance initiatives.
Tuberculosis Screening PolicyTo ensure the health and safety of our members, if you are selected for this position, your job offer with SCAN will be contingent on providing proof of Tuberculosis screening upon hire or providing proof of a negative screening within the last year. If you have a disability/medical reason or sincerely held religious belief that prevents you to provide information required in this policy, SCAN will initiate and engage in the interactive process to evaluate what, if any, reasonable accommodations may be available.
What's in it for you?Base salary range: $93,319 per year
Work Mode: Onsite
An annual employee bonus program
Medical, Dental, Vision coverage
Generous paid-time-off (PTO)
11 paid holidays per year, plus 1 additional floating holiday
Excellent 401(k) Retirement Saving Plan with employer match.
Robust employee recognition program
Robust Wellness Program
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