ECM Enrollment Specialist

• Maintain ownership of pending Medi-Cal cases from initial application through final eligibility determination.
• Regularly check application and eligibility status through BenefitsCal and other approved systems.
• Follow up with members, counties, health plans, and other appropriate entities regarding outstanding applications or eligibility issues.
• Identify missing documentation or other barriers delaying eligibility determinations and work with members to resolve them.
• Track important deadlines, notices, renewal dates, and required member actions.
• Conduct 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 determination.
• Assist members with submitting missing documentation, corrections, reconsideration requests, appeals, or other appropriate follow-up actions.
• Track appeal and reconsideration status through resolution.
• Escalate complex eligibility issues to leadership or the appropriate county/agency when additional intervention is required.
• Maintain 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 established.
• Help members navigate available MCP options within their county and complete appropriate enrollment or plan-selection processes.
• Track members awaiting MCP assignment or enrollment.
• Verify when MCP enrollment becomes active.
• Identify members assigned to an MCP outside of PHG's contracted network and explain available next steps when appropriate.
• Coordinate 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-Cal
• Pending Medi-Cal approval
• Resolving eligibility issues
• Appealing a denial or discontinuance
• Awaiting MCP assignment
• Awaiting PHG program enrollment/authorization
• Ready for handoff to the appropriate PHG team
• Verify coverage and enrollment status before transitioning members into active services.
• Coordinate closely with Member Engagement, Street Outreach, ECM, Community Supports, and other departments to ensure smooth member handoffs.
• Ensure all administrative prerequisites are completed before assigning eligible members to Lead Care Managers when applicable.
• Communicate enrollment status and outstanding barriers clearly to internal teams.

Member Communication & Support

• Maintain regular contact with prospective members throughout potentially lengthy application and enrollment processes.
• Explain complicated insurance and eligibility processes using clear, member-friendly language.
• Contact members when additional information or documentation is required.
• Provide updates regarding application status and next steps.
• Help reduce member frustration and confusion by serving as a consistent point of contact throughout the enrollment process.
• Identify 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 item.
• Maintain organized tracking of all pending enrollment cases and their current stage.
• Document unsuccessful outreach attempts and schedule appropriate follow-up.
• Ensure enrollment records are accurate, complete, HIPAA-compliant, and audit-ready.
• Provide 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 submitted
• Application approval rate
• Number of renewals completed
• Number of denied/discontinued cases successfully resolved
• Number of members successfully enrolled into an MCP
• Number of members transitioned to PHG programs
• Average time from referral to Medi-Cal application
• Average time from Medi-Cal approval to MCP enrollment
• Pending case aging
• Follow-up completion and timeliness
• Documentation accuracy and completeness

Required

• Must be bilingual in Spanish/English
• High school diploma or equivalent
• Experience in healthcare administration, insurance enrollment, eligibility, social services, patient navigation, member services, or a related field.
• Strong computer and data-entry skills.
• Excellent telephone communication and customer service skills.
• Strong attention to detail and ability to manage a large number of cases simultaneously.
• Ability to independently follow cases through multiple administrative steps until resolution.
• Ability to communicate effectively with individuals experiencing complex social and economic barriers.
• Ability to maintain confidentiality and comply with HIPAA and organizational requirements.
• Experience with Medi-Cal eligibility and enrollment.
• Experience using BenefitsCal.
• Knowledge of California Medi-Cal Managed Care Plans.
• Experience assisting with Medi-Cal applications, renewals, appeals, or eligibility troubleshooting.
• Experience working with underserved, justice-involved, unhoused, or medically complex populations.
• Experience within CalAIM, Enhanced Care Management, Community Supports, managed care, or community health programs.
• This is primarily a remote, computer- and telephone-based position.
• Requires prolonged periods of computer and telephone use.
• Must maintain a private, HIPAA-compliant remote workspace.
• Occasional travel for trainings, meetings, or organizational needs may be required.
• Exceptional organization and follow-through
• Strong administrative and documentation skills
• Ability to explain complex processes simply
• Ability to work independently in a remote environment
• Ability to recognize when an issue requires escalation
• Comfort communicating with counties, health plans, providers, and internal departments
• 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
• 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.