Lead Medi-Cal Eligibility Resolution Specialist

JOB DESCRIPTION 

Position: Lead Medi-Cal Eligibility Resolution Specialist 

Pay Range: $32.00-$38.00 PER HR 

Reporting To: CCA Manager 

Work Type: Remote

POSITION SUMMARY: 

The Lead Medi-Cal Eligibility Resolution Specialist oversees the daily operations, staff performance, and workflow of the Medi-Cal Eligibility Resolution team. This role ensures timely and accurate resolution of Medi-Cal eligibility issues, supports redetermination processes, and maintains strong relationships with county Medi-Cal offices. The Lead provides coaching, training, and operational leadership to ensure high-quality service delivery and compliance with state and federal regulations. 

QUALIFICATIONS: 

1. 2+ years of experience with Medi-Cal eligibility, public benefits, or county social services. 
2. 1+ year in a supervisory role.  
3. Strong understanding of Medi-Cal eligibility rules, documentation requirements, and county processes.  
4. Experience in working with electronic healthcare systems, and state eligibility systems. 
5. Familiar with Microsoft Word and Excel programs. 
6. Excellent communication, leadership, and problem-solving skills.  
7. Experience supervising eligibility teams in a health plan or healthcare setting.  
8. Strong analytical, organizational and communication skills.   
9. Experience in a health plan, county eligibility office or healthcare revenue cycle.  
10. Experience resolving insurance denials or appeals.   
11. Experience with insurance denials, appeals or revenue cycle operations.  
12. Familiarity with multiple county Medi-Cal workflows.  
13. Bilingual in Spanish preferred. 
14. Preferably, has a bachelor’s degree in healthcare, business administration or related field.  

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

The following is a representation of the major duties and responsibilities of this position. The agency will make reasonable accommodations to allow otherwise qualified applicants with disabilities to perform essential functions. 

1. Oversee daily workflow, caseload distribution and prioritization or urgent eligibility issues. 
2. Monitor redetermination processes to ensure timely submission and precent lapses in coverage.  
3. Serve as the primary escalation point for complex eligibility cases.  
4. Maintain strong working relationships with county Medi-Cal offices and internal departments.  
5. Review documentation for accuracy, completeness and audit readiness.  
6. Supervise Medi-Cal Eligibility Resolution Specialists, providing guidance, coaching and performance feedback.  
7. Track department performance metrics and prepare regular reports for leadership.  
8. Provide onboarding training and ongoing staff development.  
9. Conduct regular staff meetings 
10. Develop and refine workflows, SOP’s and quality standards.  
11. Collaborate with the Revenue Cycle Manager, Member Services and Compliance Officer to resolve systematic issues.  
12. Support in hiring, performance evaluations and corrective action processes.  
13. Maintain accurate, audit-ready documentation. 
14. Conduct in-person visits to county offices when necessary. 
15. Track and report eligibility trends and case outcomes. 
16. Driving may be required to county offices.  
17. Maintain confidentiality, HIPAA compliance, and knowledge of mandated reporting requirements.? 
18. Uphold agency standards, policies, and procedures as outlined in the Employee Handbook.? 
19. Participate in departmental meetings and trainings as required.? 
20. Performs other duties as assigned.? 

PHYSICAL REQUIREMENTS: 

• Stand, sit, talk, hear, and use of hands and fingers to operate computer, telephone, and keyboard on a frequent basis up to 40% of the time.  

• Reach, stoop, kneel and bend up to 20% of the time 

• Moderate amount of walking up to 15% of the time. 

• Moderate amount of driving up to 25% of the time. 

• Close vision requirements due to computer work on a frequent basis 

• Light to moderate lifting may be required up to 25lbs on a frequent basis.  

• Pushing and pulling up to 25lbs.