Medicaid Eligibility Specialist

About the role

The Medicaid Eligibility Specialist serves as an advanced resource for Medicaid eligibility, enrollment, and case resolution activities. This position is responsible for reviewing complex cases, resolving escalated issues, providing technical guidance to front-line staff, and ensuring compliance with state and federal Medicaid regulations.

Responsibilities

• Review and process complex Medicaid applications, renewals, and case changes.
• Investigate and resolve escalated eligibility issues referred by Tier 1 staff or external stakeholders.
• Analyze income, household composition, residency, citizenship, and other eligibility factors to determine Medicaid eligibility.
• Complete redeterminations and eligibility corrections within established timeliness standards.
• Ensure compliance with all federal, state, and agency policies governing Medicaid eligibility.
• Serve as the primary escalation point for complex eligibility and enrollment inquiries.
• Research policy questions and provide guidance to Tier 1 staff.
• Aid in interpreting and applying Medicaid regulations and policy updates.
• Identify system issues and collaborate with technical teams to resolve eligibility-related concerns.
• Support quality assurance efforts by reviewing cases and identifying trends or training opportunities.
• Respond to escalated member, provider, and community partner inquiries.
• Explain Medicaid eligibility decisions, enrollment requirements, and program benefits.
• Coordinate with healthcare providers, managed care organizations, and community agencies to facilitate access to services.
• Maintain professionalism and confidentiality when handling sensitive information.
• Mentor and train Tier 1 staff on eligibility processes and policy changes.
• Participate in quality audits and corrective action initiatives.
• Aid in the development and maintenance of standard operating procedures.
• Recommend process improvements to increase efficiency, accuracy, and customer satisfaction.
• Assist with Medicaid and presumptive eligibility.
• Determine and issue Presumptive Eligibility for Medicaid in compliance with state and federal guidelines.
• Clearly explain eligibility determinations, coverage timelines, and next steps to patients.
• Track and follow up on applications to ensure continuity of care and coverage.
• Promote effective working relations and work as part of a team to facilitate the organization’s ability to meet its goals and objectives.
• Collaborate with registration, billing, care teams, case management, and leadership to support patient access.
• Refer patients to internal programs and external community resources, including housing, food assistance, transportation, and social services.
• Participate in outreach events, enrollment activities, and community engagement efforts as needed.
• Provide metrics if needed to meet various GRANT funded initiatives.
• Maintain established productivity and timeliness standards.
• Achieve quality review scores of 95% or higher.
• Resolve escalated cases within established service-level agreements.
• Demonstrate expertise in Medicaid policy and serve as a resource to staff and stakeholders.
• Support agency goals related to access, enrollment accuracy, and customer satisfaction.
• Collaborate with registration, billing, care teams, case management, and leadership to support patient access.
• Refer patients to internal programs and external community resources, including housing, food assistance, transportation, and social services.
• Participate in outreach events, enrollment activities, and community engagement efforts as needed.

Qualifications

• Minimum of three (3) years of experience in Medicaid eligibility, public assistance programs, patient access, insurance enrollment, or related field.
• Experience interpreting policies and making independent eligibility determinations.
• Associate’s degree or relevant certification.
• Previous experience in an FQHC, community clinic, or safety-net healthcare setting.
• EPIC, electronic health record experience preferred.
• Experience addressing social determinants of health.