Participant Benefits Specialist

JOB SUMMARY

The Participant Benefits Specialist is responsible for managing and maintaining participant Medicaid and Medicare eligibility, ensuring accurate documentation, compliance, and timely renewals across multiple states. This role is critical in safeguarding participant coverage, advocating with state and federal agencies, and supporting the enrollment and eligibility lifecycle within the PACE program.

The Benefits Specialist collaborates closely with Social Workers, the Interdisciplinary Team (IDT), and Health Plan Operations to ensure participants receive the benefits and assistance to which they are entitled.

This is a hybrid role that requires in-person visits to the center and/or participants’ homes as needed. The primary work location may change at management’s discretion based on business needs.

ESSESNTIAL DUTIES AND RESPONSIBILITIES:

Benefits Enrollment & Maintenance

• Assist participants and caregivers with Medicaid and Medicare applications, renewals, appeals and eligibility updates.
• Navigate state-specific systems to ensure timely and accurate benefit qualification for PACE program.
• Maintain and update Medicaid renewal trackers, Medicare trackers, presumptive eligibility and termination logs monthly. Execute on new processes as developed.
• Conduct weekly reviews in Medicaid and Medicare portals or reports to identify new terminations and verify all active participants reflect PACE coverage.
• Coordinate with Social Workers on necessary spenddowns for renewals and communicate updates to the team.
• Weekly review of participants in facilities to ensure Cost Share/Patient Liability forms, insurance verification forms (IVFs), and Medicaid authorization forms are completed and submitted timely.
• Monitor and manage Electronic Data Verification (EDV) updates to ensure accurate benefit alignment.

Advocacy & Liaison Work

• Serve as a liaison between participants and state Medicaid offices, Social Security, and Medicare agencies.
• Advocate for expedited processing or resolution of benefit issues and coordinate with legal representatives for guardianships or Miller Trusts when applicable.
• Develop and maintain strong relationships with county technicians and other state contacts to ensure timely approvals.
• Coordinate with legal representatives for guardianships, Miller Trusts, or income verification needs.

Documentation & Compliance

• Maintain detailed, organized case records in compliance with HIPAA and BoldAge PACE policies.
• Ensure documentation and case files are accurately entered into the Electronic Medical Record (EMR)
• Prepare reports for internal audits and compliance reviews.
• Stay current on federal and state Medicaid and Medicare regulations (including LTC Medicaid, Spousal Impoverishment, and Trusts).

Participant Education & Support

• Educate participants and caregivers about benefits eligibility, renewals, and coverage responsibilities.
• Provide one-on-one guidance and troubleshoot benefit issues with professionalism and empathy.
• Conduct benefits orientations for new enrollees and assist with Medicare Part A or B applications as needed.
• Assist participants who elect to disenroll from BoldAgePACE with transitioning and selecting new coverage as required by State.
• Partner with Social Workers, Health Plan Operations, and the IDT to ensure accurate benefit coordination.
• Provide backup support for Enrollment Specialists on complex Medicaid cases and renewals.
• Communicate clearly with internal departments to resolve benefit-related discrepancies and maintain participant coverage continuity.

EXPERIENCE AND EDUCATION 

• High school diploma required, Associates or Bachelor’s degree in Human Services, Business, or a related field preferred.

• Minimum 3 years of experience in Medicaid, Medicare, or benefits coordination, preferably in a healthcare or PACE environment.
• Strong knowledge of Medicaid rules and application processes (including LTC, Spenddown, and State Variations).
• Experience with state systems, IVFs, EDV processes, and Medicare eligibility preferred.
• Excellent organizational and communication skills with the ability to manage multiple cases under deadlines.
• Proficiency in Microsoft Excel and EMR systems.

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.