Realignment Eligibility Program Manager-MLTSS
Role summary
Ponos Care is seeking a Realignment Eligibility Program Manager to lead eligibility and realignment functions for their Managed Long-Term Services and Supports (MLTSS) programs. This role ensures accurate and timely eligibility determinations in compliance with Medicaid and state regulations. Responsibilities include supervising Eligibility Specialists, monitoring program compliance, collaborating with clinical leadership and MCOs, and identifying process improvements. The ideal candidate will have a Bachelor's degree, 3-5 years of experience in Medicaid eligibility or healthcare coordination, and specific experience with MLTSS programs. This position requires strong analytical, communication, and leadership skills to support vulnerable populations and drive program integrity and operational excellence.
Organizational Overview
Ponos Care is a physician-led, value-based healthcare organization committed to improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions. Through compassionate care delivery, innovative treatment models, and data-informed clinical practices, Ponos Care focuses on improving health equity, enhancing patient outcomes, and reducing avoidable hospitalizations.
Through our Managed Long-Term Services and Supports (MLTSS) programs, Ponos Care ensures eligible members receive coordinated care services that improve health outcomes, reduce unnecessary hospital utilization, and enhance quality of life. Our services are delivered through interdisciplinary collaboration that promotes continuity of care and long-term stability for vulnerable populations. Ponos Care operates nationally and continues to expand its value-based care model across multiple states.
Position Overview
The Realignment Eligibility Program Manager reports to the Director, National Eligibility and Alignment and is responsible for overseeing eligibility and realignment functions supporting members requiring long-term services and supports. This leadership role ensures accurate and timely eligibility determinations in accordance with Medicaid, MLTSS, and state regulatory requirements.
The Realignment Eligibility Program Manager leads eligibility operations, supervises staff, monitors program compliance, and ensures members receive access to appropriate long-term care services including home and community-based services, personal care assistance, assisted living support, and coordinated care programs.
This role partners clinical leadership, Managed Care Organizations (MCOs), and regulatory agencies to support continuity of care, compliance, and program integrity. The Realignment Eligibility Program Manager plays a critical role in supporting vulnerable populations by ensuring efficient access to essential services.
Core Responsibilities
- Lead operational oversight of Realignment Eligibility functions supporting MLTSS programs
- Ensure accurate and timely eligibility determinations aligned with Medicaid regulatory requirements
- Supervise Eligibility Specialists responsible for screening, verification, and eligibility processing
- Monitor caseload distribution and ensure timely completion of eligibility determinations and reassessments
- Ensure eligibility documentation meets regulatory and audit readiness standards
- Review complex or escalated eligibility cases and provide guidance to staff
- Collaborate with clinical care teams to support member continuity of care
- Serve as primary contact for eligibility inquiries related to Realignment and MLTSS programs
- Promote member advocacy and ensure services are aligned with member needs and preferences
- Ensure compliance with HIPAA and privacy regulations
- Identify process improvement opportunities that improve efficiency and program outcomes
- Develop operational workflows and standard operating procedures supporting eligibility processes
- Track performance metrics related to eligibility, timeliness, accuracy, and productivity
Program Leadership & Strategy:
- Lead the development and implementation of standardized Realignment Eligibility processes supporting MLTSS programs
- Collaborate with executive leadership to support program expansion across multiple markets
- Develop eligibility frameworks aligned with value-based care initiatives
- Ensure alignment between eligibility operations and clinical care coordination programs
- Establish standardized workflows supporting scalability and operational consistency
- Provide leadership guidance supporting program compliance and quality standards
Regulatory & Compliance Oversight:
- Ensure compliance with federal and state Medicaid eligibility regulations and MLTSS requirements
- Ensure eligibility documentation meets audit readiness standards
- Maintain compliance with HIPAA and data privacy regulations
- Monitor regulatory updates impacting eligibility and MLTSS programs
- Develop internal procedures ensuring adherence to eligibility program requirements
- Identify compliance risks and implement mitigation strategies
Operational Excellence & Performance Management:
- Develop performance metrics aligned with eligibility, accuracy and timeliness standards
- Monitor eligibility processing timelines and productivity benchmarks
- Implement quality control reviews supporting accuracy and compliance
- Identify process improvement opportunities that enhance efficiency and member access
- Track eligibility outcomes and develop performance reporting dashboards
- Support continuous process improvement initiatives aligned with organizational growth
Team Leadership & Development:
- Supervise and support Eligibility Specialists and Realignment support staff
- Provide coaching and professional development guidance to staff
- Conduct performance evaluations aligned with organizational performance standards
- Promote a collaborative and compliance-focused team culture
- Support staff training related to Medicaid eligibility and MLTSS program requirements
- Ensure staff meet productivity and documentation standards
Innovation & Growth:
- Support expansion of Realignment Eligibility programs across multiple markets
- Identify opportunities to improve eligibility workflows through technology and automation
- Develop scalable processes supporting program growth and operational efficiency
- Partner with cross-functional teams to improve member access to services
- Support organizational initiatives aligned with value-based care delivery models
QUALIFICATIONS AND EDUCATION
- Bachelor’s degree in healthcare administration, Social Services, Public Administration, or related field preferred
- Minimum of 3–5 years of experience supporting Medicaid eligibility, healthcare coordination, or social services programs
- Experience working with Managed Long-Term Services and Supports (MLTSS) programs required
- Experience supervising staff or leading program operations preferred
- Knowledge of Medicaid eligibility requirements and regulatory guidelines
- Experience working with case management or eligibility systems preferred
- Strong communication and organizational skills
- Ability to manage multiple priorities and deadlines
- Strong analytical and problem-solving skills
- Ability to work collaboratively across clinical and operational teams
EEO STATEMENT
We are an Equal Opportunity Employer and are committed to fostering an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, gender identity or expression), national origin, age, disability, genetic information, veteran status, or any other protected characteristic in accordance with applicable federal, state, and local laws.
We believe inclusion strengthens our organization and enhances our ability to serve members and communities nationwide. We are committed to providing reasonable accommodation for qualified individuals with disabilities throughout the recruitment and employment process.