What are the responsibilities and job description for the Eligibility Specialist II position at Southern California United Food & Commercial Workers Unions and Food Employers Joint Benefit Funds A?
SUMMARY: Eligibility Specialist II performs all duties of Eligibility Specialist I, with additional responsibility for retiree eligibility, Medicare coordination, and complex enrollment scenarios requiring advanced knowledge of plan rules and external regulations.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Manage and maintain retiree and surviving spouse eligibility and enrollment records across Eligibility and Pension systems, ensuring accuracy and consistency.
- Process retiree and dependent Medicare documentation, including verification of Medicare eligibility, Notices of Award, and coordination of benefits in accordance with Fund rules, Medicare requirements, and HMO guidelines.
- Process retiree enrollment, dis-enrollment, plan changes, and coverage elections, including age-in 55 and age-in 65 events, residence/service-area determinations, and special handling cases.
- Establish and maintain retiree premium contribution schedules, process premium payments and reimbursements, review contribution reports, reconcile discrepancies, and refund overpayments as required.
- Set up eligibility records for surviving spouses following the death of a participant, ensuring timely continuation of coverage and proper coordination between Eligibility and Pension records.
- Confirm participant and dependent eligibility across Medicare, HMO, and plan provisions, resolve conflicts, and coordinate corrections with vendors and internal departments.
- Prepare and issue retiree enrollment and transition packets, including required notices and documentation, in accordance with plan and regulatory requirements.
- Process and communicate HMO adjustments, update vendor portal records, and report required changes to Accounting and other stakeholders.
- Review and process eligibility documentation through the imaging and workflow systems; annotate records, request missing documentation, and ensure proper record retention.
- Provide knowledgeable, responsive customer service to retirees, surviving spouses, and dependents in person and by telephone, including handling escalated or complex eligibility inquiries.
- Maintain advanced working knowledge of retiree benefits, Medicare coordination, eligibility rules, plan documents, and administrative policies.
- Meet established departmental quality, volume, and timeliness standards while independently managing complex workloads and deadlines.
- Comply with Trust Fund policies, HIPAA requirements, privacy and confidentiality standards, and attendance expectations.
- Perform other related duties as assigned to support departmental and organizational needs.
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 GED required
- Minimum of 4–5 years of experience in eligibility, benefits administration, pension fund operations, healthcare administration, or insurance, including direct responsibility for retiree eligibility and enrollment.
- Experience coordinating Medicare eligibility and benefits, verifying Medicare Parts A and B, and applying coordination-of-benefits rules with HMOs and vendors
- Ability to utilize MS Office (Excel, Word, and Outlook). Intermediate proficiency required.
Salary : $32 - $34