PACE Enrollment Specialist

Position Title: PACE Enrollment Specialist

Department: PACE

Hours per week: 40 (8:30 AM–5:00 PM, with a 30-minute unpaid lunch (8 hours paid).

Primary Function:

The PACE Enrollment Specialist supports prospective and current PACE participants with MassHealth and Medicare eligibility, applications, renewals, verifications, and ongoing enrollment requirements. The Specialist serves as a primary guide for participants, families, and caregivers navigating complex public benefits, particularly for dually eligible individuals (Medicare & MassHealth). Key responsibilities include reviewing documentation, monitoring application status, resolving coverage barriers, and ensuring a seamless transition into PACE.

The Specialist is an integral member of the Intake & Enrollment team, collaborating closely with the Interdisciplinary Team (IDT), the Insurance/Billing Department, CMS, MassHealth, and external partner agencies to ensure all eligibility, payer source, and regulatory requirements are fulfilled accurately and on schedule.

Duties & Responsibilities:

Medicare & MassHealth Eligibility Navigation

• Explain MassHealth and Medicare eligibility requirements, PACE covered benefits, and rules to prospective and current participants, families, and caregivers.
• Conduct preliminary eligibility reviews, including income, assets, Medicare Parts A, B, and D status, supplemental insurance, and other applicable payer requirements.
• Educate prospective enrollees on how PACE integrates Medicare and Medicaid benefits into a single comprehensive model, including the requirement to receive all primary, specialty, and prescription drug care through the PACE network.
• Identify potential eligibility barriers, spend-downs, or coverage discrepancies and coordinate resolution with appropriate team members.
• Serve as an internal subject matter resource on MassHealth and Medicare eligibility.

Compliance & Quality

• Prepare Written Notices & Determination Letters: Draft, finalize, and issue timely written notification letters for prospective participants who do not meet clinical, geographic, or financial eligibility criteria (denial of enrollment), as well as required notices for participants facing involuntary disenrollment (e.g., loss of MassHealth eligibility, relocation outside service area, failure to pay cost share, disruptive behavior/safety reasons) in accordance with CMS regulations, MassHealth rules, and organizational policies, ensuring proper inclusion of grievance and appeal/fair hearing rights.
• Audit Preparation & Support: Participate in CMS and MassHealth audits, regulatory site visits, and state oversight reviews, including preparing documentation, participant files, and enrollment logs.
• Quality Improvement: Participate in continuous quality improvement initiatives regarding Intake & Enrollment processes, application cycle times, conversion rates, and retention workflows.
• Regulatory Adherence: Maintain confidentiality and strict adherence to HIPAA, CMS marketing 
• guidelines, MassHealth contractual obligations, and culturally competent care standards.
• General: Perform other duties as assigned.

Intake & Enrollment Support

• Facilitate communication among participants, families, caregivers, and the Interdisciplinary Team (IDT).
• Provide relevant participant information and documentation to support IDT review, transition, and care planning for new enrollees.
• Maintain tracking systems for enrollment activities, reassessments, eligibility requirements, and regulatory deadlines.

Minimum Basic Knowledge:

• Familiarity with MassHealth applications, renewals, redeterminations, and eligibility verification processes.
• Understanding of PACE enrollment requirements and how MassHealth eligibility impacts PACE enrollment and continued participation.
• Knowledge of confidentiality requirements and appropriate handling of sensitive participant and financial information.
• Understanding of Medicare qualifications

• Proficiency with electronic health records and administrative systems; experience with PACE Care Online, OCHIN, EPIC, or similar systems preferred.
• Competent with Microsoft Office applications, including Word, Excel, and Outlook.

• Ability to work independently and collaboratively across departments while maintaining appropriate follow-up and accountability.
• Ability to maintain professionalism, cultural sensitivity, and participant-centered service when working with individuals from diverse backgrounds.

Experience & Qualifications:

• Experience completing MassHealth applications
• Experience or knowledge of enrolling someone in Medicare
• Knowledge of MassHealth and Medicare benefits
• Bilingual skills preferred, particularly English/Spanish, Portuguese Creole, or Haitian Creole.
• Must have a valid driver's license.

Essential Functions:

• Ability to work effectively with participants, families, caregivers, MassHealth representatives, and interdisciplinary teams
• Strong organizational and time-management skills, with the ability to track multiple applications, deadlines, documentation requirements, and follow-ups. Strong attention to detail and ability to review documents for completeness, accuracy, and discrepancies.
• Excellent written, verbal, and interpersonal communication skills, with the ability to explain complex eligibility requirements in clear, understandable language.

Physical Requirements:

• Desk & Computer Work: Prolonged periods of sitting at a desk, typing, reviewing small print and digital records, and managing multi-line phone/video communications.
• Driving & Community Travel: Regular local travel throughout the service area to meet participants/caregivers, conduct intake visits, or attend community presentations; requires physical ability to safely operate a motor vehicle.
• Lifting & Carrying: Occasional lifting, carrying, pushing, and pulling of outreach kits, portable computers, and document boxes weighing up to 15–20 lbs.
• Mobility & Physical Agility: Ability to stand, bend, walk, and navigate stairs or uneven surfaces 
• when conducting visits in community venues or participant home environments.
• Sensory Demands: Visual acuity adequate to inspect legal and financial documentation and work on computer screens; clear auditory and speech capabilities to converse effectively in person and by phone.

Supervisory Responsibility: None   

Define Access Level to PHI: Level 2