Eligibility Operations Coordinator

Description

About Us:

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY: The Eligibility Operations Specialist maintains accurate member eligibility data, manages C SNP verification, and supports compliance-driven tasks through timely processing of member data and Medicare Secondary Payer (MSP) activities. The role serves as a key liaison across internal teams, providers, and regulatory systems to ensure adherence to CMS requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Process incoming mail, emails, and faxes related to C SNP verification and MSP activities.
• Review provider verification forms and document qualifying chronic conditions per CMS guidelines.
• Prepare and maintain member and provider correspondence, including letters and faxes.
• Track and complete department tasks within required CMS timeframes.
• Conduct outbound calls to verify coverage and update records timely.
• Submit ECRS terminations and eligibility updates according to CMS and internal procedures.
• Ensure all documentation is accurate, complete, and audit ready.
• Research and resolve eligibility discrepancies.
• Maintain daily Coordination of Benefits (COB) and other related files. 
• Follow up on outstanding items to ensure timely resolution.
• Collaborate with internal teams to support efficient workflows.
• Maintain regular and consistent attendance.
• Perform other duties as assigned
• Regular and consistent attendance
• Other duties as assigned 

Requirements

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• High school diploma or equivalent required
• Minimum 2+ years’ experience with Medicare Advantage required
• Working knowledge of Medicare, Medicaid, CMS regulations, MSP requirements and C-SNP eligibility requirements preferred.
• Previous experience in administrative support, healthcare operations, or insurance processing preferred. 
• Excellent verbal and written communication skills. 
• Strong organizational skills with the ability to manage multiple priorities and regulatory deadlines while maintaining accuracy. 
• Demonstrate the ability to work independently and prioritize workload while maintaining accuracy and productivity.
• Ability to identify issues, determine appropriate next steps and seek guidance when necessary. 
• Proficient in Microsoft Office applications, primarily Excel and Word.
• Excellent communication and interpersonal skills. 

OTHER SKILLS and ABILITIES:

• Excellent computer skills and working knowledge of common office software.
• Ability to prioritize and multi-task.
• Exemplary verbal and written communication skills.

BENEFITS:

• 401(k)
• Dental Insurance
• Health Insurance
• Life Insurance
• Vision Insurance
• Paid Time Off

LANGUAGE: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups and customers or employees of the organization.

MATHEMATICS: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

EEO/AFFIRMATIVE ACTION STATEMENT: It is the policy of Astiva Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law. This policy relates to all phases of employment, including but not limited to recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and termination, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the organization where appropriate. Please refer to Standard Operating Procedure 100 for more information about the organization’s Affirmative Action/EEO statement.  

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit and complete work while on a computer. The employee occasionally is required to stand, walk, use hands to finger, handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, talk and hear.

While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Employee signature below indicates the employee’s understanding of the requirements, essential functions and duties of this position.