Medicare Eligibility Specialist

Internally titled: Eligibility Specialist

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what.

The Eligibility Specialist is accountable for proactively addressing complex eligibility challenges and ensuring seamless participant coverage. This role works directly with CMS, DHCS, and county Medicaid offices to troubleshoot eligibility issues, correct misalignments, and advocate for participants’ eligibility for the PACE program. This role also plays a key part in training internal teams, including Outreach & Enrollment and Social Work teams, to enhance organizational knowledge and prevent eligibility-related disruptions.

This role is different because the Eligibility Specialist at WelbeHealth:

• Plays a critical role in securing life-sustaining coverage for vulnerable seniors, working hand-in-hand with Medi-Cal, Medicare, and Social Security agencies to remove barriers so participants can access comprehensive PACE services without interruption
• Operates at the intersection of outreach, enrollment, eligibility, and revenue cycle, giving this role broader visibility and impact than traditional eligibility positions, and directly influencing program access and participant experience

We care about our team members. That’s why we offer:

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance - We mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days
• 401K savings + match
• Comprehensive compensation package including base pay and bonus
• And additional benefits!

On the day-to-day, you will:

• Act as an organizational expert in Medicare or Medicaid eligibility policies and keep teams informed of regulatory updates
• Provide guidance to leadership, internal teams, and stakeholders on eligibility cases, processes, and compliance requirements
• Oversee resolution of complex eligibility issues, including coverage misalignments, retroactive enrollments, reinstatements, and eligibility corrections
• Work directly with CMS, DHCS, and county agencies to troubleshoot eligibility discrepancies and secure accurate benefit assignments
• Advocate for participants in disputed eligibility cases to minimize gaps in coverage
• Develop and deliver training programs for internal teams to improve eligibility accuracy and efficiency, as well as maintain knowledge repositories, job aids, and process documentation to support staff in handling eligibility cases
• Monitor and analyze enrollment and eligibility data (e.g., DTRR, 834, 820, MMR) to identify trends, discrepancies, and risks

Job requirements include:

• Associate’s degree in relevant field; relevant experience may be substituted
• Minimum of three (3) years of experience in Medicare is a must for the role
• Minimum of one (1) year of experience working with governmental agencies
• Excellent leadership, organizational and communication skills in settings with seniors, their families and interdisciplinary team members
• Experience leading in a data-driven organization, leveraging reports and data to prioritize and manage people and projects

We are seeking an Eligibility Specialist that ideally has over three (3) years of experience in Medicare eligibility. If you’re ready to join a team that values both its participants and team members, we’d love to hear from you!