Operations

• Champion Enrollment Success – Develop and manage seamless processes for participant Medicaid/Medi-Cal and Medicare enrollment, ensuring they maintain access to vital benefits.
• Keep Workflows on Track – Maintain accurate, real-time tracking for all eligibility and enrollment workflows across Medicare and Medi-Cal.
• Be a Pre-Enrollment Pro – Partner with LA County, IHSS, and Social Security to confirm all participant data is up-to-date, synced, and ready for enrollment.
• Own Part D Operations – Manage Part D enrollment and eligibility within Centers for Medicare & Medicaid Services systems (MARx, eRPT, COB, Transaction Facilitators), lead audits, and oversee retroactive eligibility processing.
• Drive Redetermination Efforts – Oversee California Department of Health Care Services (DHCS) redetermination data and collaborate with Social Workers to support timely renewals.
• Solve Complex Eligibility Issues – Lead troubleshooting for Part D plan operations including TROOP, PDE, and RAPS rejections.
• Deliver Personalized Support – Provide one-on-one assistance to PACE participants with warmth, care, and exceptional service.
• Guide Medicare Age-Ins – Support participants as they transition into Medicare, making the process smooth and stress-free.
• Track and Monitor with Precision – Oversee self-pay billing activities in partnership with Finance and TPA teams.
• Master the Data Game – Manage monthly enrollment reconciliations, capitation files, and vendor rosters to keep our systems aligned and accurate.
• Support Seamless Transitions – Assist enrollment and disenrollment teams with DHCS submissions, tracking, and compliance activities.
• Ensure Timely Authorizations – Monitor internal authorization workflows, ensure prompt prior authorizations, and conduct retro-reviews of unauthorized services.
• Be Audit-Ready Always – Document and support audit activities to maintain stellar health plan oversight.
• Oversee Participant Materials – Coordinate ID card requests and ensure ADA-compliant materials are delivered on time.
• Stay on Top of Regulations – Manage ongoing Part D regulatory reporting requirements with diligence and attention to detail.
• Wear Many Hats – Step in with all other duties as needed to help our mission thrive!

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