Health Plan Specialist REMOTE

• A People First Environment: We make what is important to those we serve important to us.
• Make an Impact: Enhance the quality of life for seniors.
• Professional Growth: Access to training and career development.

• Medical/Dental
• Generous Paid Time Off
• 401K with Match*
• Life Insurance
• Tuition Reimbursement
• Flexible Spending Account
• Employee Assistance Program

JOB SUMMARY:

The Health Plan Specialist is responsible for supporting enrollment, eligibility, revenue operations, and data analysis across PACE programs. This role ensures accurate, compliant, and timely management of Medicare, Medicaid, and self-pay participant enrollment. This role is expected to investigate, own, and drive resolution of complex enrollment and eligibility issues through to completion.

This position serves as a key liaison between Revenue Cycle, local PACE sites, and external stakeholders, ensuring alignment across enrollment workflows, regulatory requirements, and financial outcomes. The role combines hands-on operational execution with data-driven analysis and process improvement.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Enrollment and Eligibility Management

• Ensure accurate and timely enrollment and disenrollment of participants across Medicare, Medicaid, and self-pay lines of business 
• Validate participant eligibility and maintain supporting documentation in compliance with internal policies and regulatory requirements 
• Identify and drive resolution of discrepancies impacting eligibility, coverage, and enrollment status 
• Manage enrollment and eligibility data files and data transfer processes supporting PACE operations (e.g., CMS, state submissions, internal systems) 
• Review and troubleshoot enrollment transactions and data files to identify errors, rejects, and inconsistencies
• Monitor enrollment trends, data accuracy, and operational metrics to support decision-making 
• Communicate with state agencies, CMS, and vendors regarding eligibility, enrollment issues, and regulatory requirements 
• Research and document state-specific eligibility rules and enrollment workflows; provide recommendations for operational improvements 

Revenue and Financial Operations Support

• Ensure alignment between eligibility status and revenue capture processes
• Coordinate with revenue cycle, finance, and local PACE programs to identify, track, and resolve issues involving patient liability, share of cost, Medicare Only, and self-pay obligations
• Assist in resolving discrepancies related to eligibility, coverage, or billing 
• Identify, track, and resolve issues that may result in lost or delayed revenue (e.g. enrollment gaps, eligibility mismatches)

• Support reconciliation of enrollment data against capitation, billing, and payment records

 Program Operations and Site Collaboration

• Serve as a liaison between Revenue Cycle and local PACE programs 
• Provide reporting and actively participate in regular meetings with sites to review enrollment, eligibility, and financial performance metrics 
• Provide training and guidance to site staff on: 

• Enrollment processes 
• Eligibility requirements 
• Health plan workflows 

• Support cross-functional collaboration to ensure consistent execution across all programs 

Compliance, Audits, and Regulatory Support

• Support regulatory and internal audits, including: 

• One-third financial audits 
• Medicare Part D function and audits 
• Enrollment Data Verification (EDV) 
• State and CMS program reviews 

• Ensure compliance with federal, state, and CMS regulations related to PACE and health plan operations 
• Maintain documentation and audit readiness across enrollment and eligibility processes 
• Support government relations and policy tracking related to eligibility and enrollment requirements 

Data Analysis and Reporting

• Perform operational and financial analysis related to enrollment, eligibility, and program performance 

• Use data analysis to proactively identify risks enrollment accuracy and revenue performance
• Develop and maintain reports and dashboards tracking: 

• Enrollment trends 
• Eligibility status and discrepancies
• Revenue risks and impacts 
• Operational KPIs 

• Provide insights and recommendations to leadership to support strategic planning and performance improvement 

Process Improvement and Operational Support

• Identify inefficiencies and operational risks within enrollment and eligibility workflows 
• Recommend and implement process improvements to enhance accuracy, efficiency, and participant experience 
• Communicate process updates and policy changes across programs 
• Support system implementations, workflow enhancements, and expansion into new markets or sites 
• Partner with Participant Benefit Specialists and site teams to promote consistent and compliant enrollment practices
• Perform other duties as assigned to support departmental and organizational goals 

EXPERIENCE, EDUCATION AND CERTIFICATIONS:

• Bachelor’s degree preferred or equivalent experience 
• 2–4+ years of experience in healthcare operations, managed care, PACE, or eligibility/enrollment 
• Strong knowledge of: Medicare and Medicaid eligibility, enrollment processes and regulatory requirements ,health plan revenue cycle fundamentals 
• Experience working across multiple states preferred 

PRE-EMPLOYMENT REQUIREMENTS:

• Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.    
• Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.    
• Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen. 

BoldAge PACE provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. 

* Match begins after one year of employment