Medical Eligibility Specialist (CC0707 - East)

Medical Eligibility Specialist (CC0707 - East)

As an essential part of CommuniCare and the community, serves as an intermediary between patients, community members, providers, and government entities to navigate complex insurance programs and funding sources available. Ensures accurate and efficient application processing and counseling to patients and community members by keeping up to date with regulations and related processes. Facilitates client qualification for and enrollment in a Qualified Health Plan (QHP) through the Federal Marketplace, Medicaid/CHIP and/or other health programs/grants. Assists eligible individuals in making informed decisions on the selection of a health plan if available. Maintains confidentiality of all patient information.

DUTIES AND RESPONSIBILITIES:

• Processes Medicaid, Marketplace and Sliding Fee Scale applications, ensuring all required documentation is complete and accurate by analyzing applicants' financial and medical information in accordance with federal and state guidelines. This includes all internal and external patients seeking assistance with Medicaid/Marketplace subscriptions.
• Performs new patient registration, including data entry of demographics, and any other required information. Verifies third party benefit coverage to include co-pays, deductibles and co-insurance. Ensures accurate activations of plans and programs and records special notations in patient account software.
• Offers guidance and support to applicants and beneficiaries regarding benefits, coverage limits, and the renewal processes. Ensuring fair and accurate assessments based on eligibility criteria. Patience for people when teaching, using active listening skills while actively teaching packages and insurance choices.
• Investigate and resolve discrepancies or issues related to program eligibility, benefits, and claims, including potential fraud cases by engaging with state and federal agencies to ensure compliance with Medicaid/Marketplace policies and regulations.
• Performs the follow-up eligibility process, including contacting the patient for additional information, providing additional information required by programs, and contacting the funding source for eligibility status.
• Maintains knowledge and expertise in eligibility, enrollment, and program specifications of the Federal Marketplace, Texas Community Partner Program, grant funding sources, and other health coverage programs. Completes annual training as required to be compliant with departmental policies and funding source requirements.
• Ensures the protection and security of consumers' personal, confidential and identifiable information in a professional and responsible manner, according to the standards and requirements of the Health Insurance Portability and Accountability Act (HIPAA). Conducts rigorous audits and reviews of Medicaid activities and provider services to ensure adherence to regulations; safeguarding the program's integrity and preventing legal and financial issues.
• Assists with developing and delivering training sessions on Medicaid, Marketplace and Sliding Fee policies to new staff. Collaborates interdepartmentally to verify patient eligibility for coverage and to facilitate billing processes. Provides support for insurance verification, entering demographics, program eligibility, payment processing, and related tasks.
• Answers calls and schedules appointments through the concierge line for employees.
• Provides exceptional internal and external customer service. Communicate with clients, support staff and third party payors to address billing questions and concerns regarding charges, payments, adjustments, benefits and possible refunds. Makes payment plan arrangements with patients when appropriate.
• Performs other related duties as assigned.

JOB QUALIFICATIONS:

• High School graduate or equivalent required
• Minimum one year experience in front office duties, including insurance verification and referrals
• Must complete up to 60 hours of training to obtain Federal Consumer Assistance and Texas Case Assistance Navigator certifications within six (6) months of service in position and recertification on an annual basis
• Proficiency in Word, Excel, Internet/Intranet and EHR (Electronic Health Record) data entry skills
• Has knowledge in healthcare billing, to include Medicaid, Medicare, and Private Insurance
• Demonstrates good verbal and written communication, with interpersonal and organizational skills
• Ability to handle multiple tasks ensuring completion with minimal supervision and attention to detail
• Bilingual (English/Spanish) preferred
• Scheduled hours and/or work locations are subject to change

PHYSICAL ACTIVITIES AND REQUIREMENTS:

• Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects.
• Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly.
• Hearing: Able to hear average or normal conversations and receive ordinary information.
• Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers.
• Visual: Average, ordinary, visual acuity necessary to prepare or inspect documents or other materials.
• Physical: Sedentary work; sitting most of the time. May have to lift folders, files, papers, audio/video equipment, and other such items weighing up to approximately 25 lbs.

Qualifications:

Education: High School/GED or better in General Business.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

CommuniCare Health Centers (Texas)