ECM Enrollment Specialist

Location: Remote Employment Type: Full-Time Schedule: Monday-Friday, 8:00 AM-4:30 PM Work Environment: Remote Reports To: Member Engagement/Enrollment Leadership Compensation: $22.00 - $24.00 per hour, depending on experience and qualifications. About Pacific Health Group At Pacific Health Group, we care deeply about the people and communities we serve. We meet individuals with kindness, respect, and understanding—listening first, honoring each person's journey, and offering support without judgment. Through compassionate, person-centered healthcare, behavioral health services, and social supports, we help individuals navigate barriers to care and connect with the services they need to achieve greater health, stability, and independence. Role Overview & Impact The Enrollment Specialist is responsible for helping prospective Pacific Health Group members navigate the administrative steps required to obtain and maintain healthcare coverage and become eligible for PHG services. Many individuals identified through Pacific Health Group's outreach efforts are uninsured, have inactive Medi-Cal coverage, have pending applications, need assistance completing a renewal, or are not yet enrolled with the appropriate Medi-Cal Managed Care Plan (MCP). The Enrollment Specialist takes ownership of these cases and works to move members through the coverage and enrollment process as efficiently as possible. This position assists individuals with Medi-Cal applications and renewals, monitors pending applications, follows up on eligibility issues, assists with denied or discontinued coverage, supports appeals and submission of requested documentation, helps members navigate Managed Care Plan enrollment, and tracks each case until the individual is ready to transition into PHG's applicable programs. The Enrollment Specialist serves as the administrative bridge between initial member engagement and active program enrollment, allowing care management staff to focus on members who are ready to receive services. Why This Role Matters For many individuals served by Pacific Health Group, lack of active insurance coverage is one of the first barriers preventing access to care. The Enrollment Specialist helps remove that barrier by ensuring individuals do not become lost during lengthy or complicated Medi-Cal processes. Through persistent follow-up, accurate documentation, and hands-on navigation assistance, this position helps move prospective members from uninsured or pending status to active coverage and program readiness. Key Responsibilities Medi-Cal Application & Enrollment Assistance Assist uninsured prospective members with completing and submitting Medi-Cal applications through BenefitsCal or other applicable enrollment channelsGuide members through the application process and explain required documentation, verification requirements, and next stepsAssist members with Medi-Cal renewals and redeterminations when coverage is approaching expiration or has been discontinuedHelp members gather and submit requested eligibility documentationReview applications for completeness and accuracy before submission whenever appropriateEducate members on the Medi-Cal enrollment process and expected next steps in clear, easy-to-understand language Application Status & Eligibility Follow-Up Maintain ownership of pending Medi-Cal cases from initial application through final eligibility determinationRegularly check application and eligibility status through BenefitsCal and other approved systemsFollow up with members, counties, health plans, and other appropriate entities regarding outstanding applications or eligibility issuesIdentify missing documentation or other barriers delaying eligibility determinations and work with members to resolve themTrack important deadlines, notices, renewal dates, and required member actionsConduct persistent follow-up to prevent applications from becoming delayed, abandoned, or closed unnecessarily Denials, Discontinuances & Appeals Review Medi-Cal denial, discontinuance, or request-for-information notices with members and help identify the reason for the determinationAssist members with submitting missing documentation, corrections, reconsideration requests, appeals, or other appropriate follow-up actionsTrack appeal and reconsideration status through resolutionEscalate complex eligibility issues to leadership or the appropriate county/agency when additional intervention is requiredMaintain detailed documentation of all actions taken and outstanding requirements Managed Care Plan Enrollment Assist members with understanding Medi-Cal Managed Care Plan enrollment after Medi-Cal eligibility is establishedHelp members navigate available MCP options within their county and complete appropriate enrollment or plan-selection processesTrack members awaiting MCP assignment or enrollmentVerify when MCP enrollment becomes activeIdentify members assigned to an MCP outside of PHG's contracted network and explain available next steps when appropriateCoordinate with internal teams once the member's coverage and MCP status allow PHG enrollment activities to proceed ECM & Program Readiness Maintain a clear pipeline of prospective members who are:Applying for Medi-CalPending Medi-Cal approvalResolving eligibility issuesAppealing a denial or discontinuanceAwaiting MCP assignmentAwaiting PHG program enrollment/authorizationReady for handoff to the appropriate PHG teamVerify coverage and enrollment status before transitioning members into active servicesCoordinate closely with Member Engagement, Street Outreach, ECM, Community Supports, and other departments to ensure smooth member handoffsEnsure all administrative prerequisites are completed before assigning eligible members to Lead Care Managers when applicableCommunicate enrollment status and outstanding barriers clearly to internal teamsMember Communication & Support Maintain regular contact with prospective members throughout potentially lengthy application and enrollment processesExplain complicated insurance and eligibility processes using clear, member-friendly languageContact members when additional information or documentation is requiredProvide updates regarding application status and next stepsHelp reduce member frustration and confusion by serving as a consistent point of contact throughout the enrollment processIdentify urgent needs disclosed during enrollment conversations and escalate or connect the individual with appropriate resources according to PHG protocols Case Tracking & Documentation Maintain accurate and timely documentation of every member interaction, application update, eligibility determination, appeal, MCP assignment, and outstanding action itemMaintain organized tracking of all pending enrollment cases and their current stageDocument unsuccessful outreach attempts and schedule appropriate follow-upEnsure enrollment records are accurate, complete, HIPAA-compliant, and audit-readyProvide leadership with regular reporting regarding pending cases, processing delays, denials, approvals, MCP assignments, and completed enrollments Performance Expectations Success in this role requires strong ownership of the enrollment pipeline. The Enrollment Specialist is expected to actively move cases forward rather than simply record their current status. Key performance indicators may include: Number of Medi-Cal applications submittedApplication approval rateNumber of renewals completedNumber of denied/discontinued cases successfully resolvedNumber of members successfully enrolled into an MCPNumber of members transitioned to PHG programsAverage time from referral to Medi-Cal applicationAverage time from Medi-Cal approval to MCP enrollmentPending case agingFollow-up completion and timelinessDocumentation accuracy and completeness Qualifications Required Must be bilingual in Spanish/EnglishHigh school diploma or equivalentExperience in healthcare administration, insurance enrollment, eligibility, social services, patient navigation, member services, or a related fieldStrong computer and data-entry skillsExcellent telephone communication and customer service skillsStrong attention to detail and ability to manage a large number of cases simultaneouslyAbility to independently follow cases through multiple administrative steps until resolutionAbility to communicate effectively with individuals experiencing complex social and economic barriersAbility to maintain confidentiality and comply with HIPAA and organizational requirements Preferred Experience with Medi-Cal eligibility and enrollmentExperience using BenefitsCalKnowledge of California Medi-Cal Managed Care PlansExperience assisting with Medi-Cal applications, renewals, appeals, or eligibility troubleshootingExperience working with underserved, justice-involved, unhoused, or medically complex populationsExperience within CalAIM, Enhanced Care Management, Community Supports, managed care, or community health programs Skills & Competencies Exceptional organization and follow-throughPersistence and problem-solvingStrong administrative and documentation skillsMember-centered communicationAbility to explain complex processes simplyAttention to detailTime managementCase tracking and pipeline managementCritical thinkingProfessional telephone communicationAbility to work independently in a remote environmentAbility to recognize when an issue requires escalationComfort communicating with counties, health plans, providers, and internal departments What Success Looks Like A successful Enrollment Specialist does not allow prospective members to become lost between outreach and active services. They know where every pending member stands, what is preventing the case from moving forward, what needs to happen next, and who needs to be contacted to make it happen. They proactively follow applications and eligibility issues through resolution and ensure that once a member becomes eligible for PHG services, the appropriate internal team is notified and the member is transitioned without unnecessary delay. Physical Requirements & Work Environment This is primarily a remote, computer- and telephone-based positionRequires prolonged periods of computer and telephone useMust maintain a private, HIPAA-compliant remote workspaceOccasional travel for trainings, meetings, or organizational needs may be required Benefits 401(k) matchingDental insuranceHealth insuranceLife insurancePaid time offVision insurance Pacific Health Group is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to any characteristic protected by applicable federal, state, or local law.