About this role
Function(s):
The Medicaid Specialist is responsible for ensuring accurate, timely and compliant Medicaid eligibility, enrollment, redetermination and waiver operations across multiple state and managed care systems.
JOB RESPONSIBILITIES:
Provide enrollee-related support to Care Management and Assessment Departments and staff
- Process and resolve daily alerts identifying eligibility changes, share of cost updates, plan flips and system discrepancies across Ohio Benefits, Provider Network Management, Master List, PIMS and MCO portals.
- Complete chart assignments and closures with full documentation and cross-system verification.
- Manage reinstatements of Medicaid eligibility, ensuring timely correction of eligibility interruptions to prevent service gaps.
- Perform Share of Cost processing daily, ensuring accuracy and compliance with waiver requirements.
- Process disenrollments across multiple MCO’s including PASSPORT/Assisted Living, MyCare CareSource, Molina, Anthem and Buckeye.
- Complete mailing of State Hearing rights.
- Conduct continuous monitoring of eligibility changes across Ohio Benefits, PNM, master list, PIMS and MCO systems, identifying discrepancies and initiating corrective action.
- Maintain and update tracking logs for state-funded cases, closures, reinstatements, Assisted Living enrollments/disenrollments, share of cost, and other eligibility actions.
- Perform accurate and reconciled monthly and quarterly reporting, including:
CareSource Vendor report
- CareSource billing
- MAGI report
- Medicaid Renewal Reports
- PIMS Waiver Enrollment Report
- Transitions/Flip reports
- Suspension Report
- Molina Audit Report
- Any evolving reports that are required as Next Generation
- Serve as primary liaison to County JFS, Managed Care Organizations, Ohio Department of Medicaid and Ohio Department of Aging regarding eligibility, Share of Cost and waiver enrollment issues.
- Initiate and track escalations for eligibility errors, system mismatches, and billing discrepancies.
- Coordinate with Care Managers/WSCs to communicate eligibility changes, plan updates and SOC adjustments.
- Advocate for timely Medicaid approvals and resolve conflicts through direct communication with state and county partners.
- Navigate and maintain proficiency in multiple state and program systems, including OB (Ohio Benefits), PNM (Provider Network Management), Master List, PIMS, MCO portals (MyCare CareSource, Moline, Anthem and Buckeye).
- Perform data entry and documentation across all systems.
Upload required documentation into agency and program-specific systems.
Qualifications
Required:
- 1 year of relevant experience.
- High School diploma
Preferred:
- Intermediate experience with Microsoft Office programs including Excel, Outlook, Word and Access database use.
- Previous data entry experience
- Previous insurance billing experience
- Some college education