Eligibility & Enrollment Specialist

Description

Eligibility & Enrollment Specialist

This is a new position at Community Health & Wellness Partners. Perfect for that detailed individual that has interest and understanding of insurances such as Medicaid, Medicare, private health plans, or social service programs

Job Title: Integrated Health Eligibility and Enrollment Specialist

Department: Clerical

Time Commitment: Full-time

Reports To: IH Eligibility and Enrollment Coordinator

FLSA Status: Non-Exempt

Location: Bellefontaine, Indian Lake, West Liberty, Urbana, DeGraff, and School-Based Health Centers 

Summary

Under the guidance of the Integrated Health Eligibility and Enrollment Coordinator, the Integrated Health Eligibility and Enrollment Specialist is responsible for managing, coordinating and integrating the eligibility determination and enrollment processes for Community Health & Wellness Partners patients. The Integrated Health Eligibility and Enrollment Specialist possesses and demonstrates an advanced and comprehensive understanding of community, government, and private social services/agencies and programs. They will serve as an informational resource to patients and staff members. This includes eligibility requirements and procedures to effectively support the recruitment, registration, enrollment and retention of consumers to the ACA Marketplace, Medicare Part D stand-alone prescription drug plans, Medicare Advantage plans, Ohio Medicaid, or discount programs as well as referrals to social services or agencies. This role ensures compliance with applicable policies, regulations, and standards while providing excellent patient-centered care and support.

Primary Accountabilities

Achieve Results

• Review applications and supporting documentation to determine patient eligibility for programs and services.
• Interpret and apply eligibility guidelines and regulatory requirements accurately.
• Maintain up-to-date knowledge of federal, state, and organizational eligibility criteria.

Operational Excellence

• Ensure that all information collected, processed, entered and filed is done in a timely, accurate manner.
• Ensure and uphold the confidentiality requirements of all patient records and manage all daily tasks and activities consistent with HIPAA, state and federal laws and regulations, as well as the health center policies and regulations regarding confidentiality and security.

Relationship Management

• Develop and ensure effective, positive relationships with all patients, staff, vendors, contractors and related resources.
• Develop and ensure ongoing, positive relationships and collaboration with other providers, nurses, administrative and clinic operations staff. 
• Ensure the success of each clinic operation through collaborative support and working relationships with all clinic operations staff.

 Stewardship and Professionalism

• Ensure all actions, job performance, personal conduct and communications always represent the organization in a highly professional manner.
• Uphold and ensure compliance with and attention to all corporate policies and procedures, as well as the mission and values of the organization.

Primary Tasks & Duties

• Facilitate and process the enrollment of eligible individuals into applicable programs (Medicaid, Medicare, private health plans, or social service programs)
• Answer questions from patients, coworkers and insurance companies.
• Track application status, follow up on incomplete submissions, and communicate enrollment decisions to applicants in a timely manner.
• Coordinate with case managers, outreach associates, and other departments to ensure seamless delivery of services.
• Enter and maintain up-to-date client information in databases and systems.
• Generate reports on enrollment activity, eligibility determinations, program metrics, and submission of data reporting to agencies as required.
• Identify and provide outreach to patients that may be eligible for additional assistance.
• Serve as the primary point of contact for eligibility and enrollment inquiries.
• Resolve issues or discrepancies related to eligibility and enrollment and make referrals as indicated.
• Ensure compliance with all applicable laws, regulations and policies.
• Work directly with patients to help them complete all necessary enrollment processes.
• Navigate resources to reduce out-of-pocket expenses for patients by identifying assistance programs for which they might be eligible for.
• Research and verify patient eligibility for different programs and insurance coverage.
• Review and evaluate self-pay accounts for potential payment sources and initiate outreach.
• Registering and interviewing patients to obtain accurate demographic and financial information.
• Perform month-end and year-end reports
• Identifies work processes and strives to improve quality improvement throughout the organization
• Other duties as assigned.

Essential Functions/Key Competencies                      

• Function in a multi-tasking, multiple priorities environment, while maintaining accuracy and attention to detail.
• Communicate with a diverse, sometimes difficult, patient/consumer population.  Will be required to successfully manage patients and families in often stressful or conflict situations.
• Utilize a wide variety of office technology and tools to collect, enter, process, file patient records and documentation, including Federal and state platforms.
• Analytical skills are necessary to screen patients appropriately.
• Demonstrate a high level of skill at building relationships and customer service.
• Demonstrate interpersonal savvy and influence skills in managing difficult clients and patients.
• Demonstrate a high level of problem-solving skills to better serve patients and staff.
• Demonstrates an understanding of and proficiency with the application of all Joint Commission Accreditation standards and reporting requirements applicable to this role.
• Strong attention to detail and accuracy.
• Ability to utilize computers for data entry and information retrieval.
• Excellent verbal and written communication skills.
• Ability to implement and evaluate operational and administrative processes.
• Participate in aspects related to quality compliance, improvement and risk management for a Federally Qualified Health Center
• Engage in certification projects, i.e. PCMH, JACHO, NAQH
• Engage in all corporate compliance requirements of Community Health & Wellness Partners of Logan County

Qualifications

Qualifications & Requirements

Education

• Preferred associate’s degree in medical Billing, Business, Finance, Healthcare Administration, Case Management or Social Work.  Experience may be considered in lieu of Degree, or another Degree could be considered.
• Previous experience in determining eligibility and completing follow up for Government Programs.

    Certificates and Licenses      

• Valid Ohio driver's license
• SHIP/Ohio State Health Insurance Program Counselor Certification – Current or required within the first year of employment and renewed annually.
• Federally Facilitated Marketplace Certified Application Counselor Certification for the Health Insurance Marketplace (FFM-CAC Assister) – Current or required within the first year of employment and renewed annually.

Professional

• Strive to serve Community Health & Wellness Partners’ Mission by providing quality, whole-person, patient-centered medical care to anyone and everyone in our community. 
• Keep the organization’s Vision in mind to change lives within our community by eliminating barriers and providing a standard of healthcare that improves the well-being of the whole person.
• Support the Values of CHWP (BLESSED):

Be welcoming

Listen with heart

Educate patients

Serve with excellence

Share best practices

Eliminate barriers

Develop relationships

• Practical knowledge of entitlement programs, Medicaid and Medicare, and third-party billing. 
• Experience in use of electronic practice management system(s) including practice management system set-up and reporting. 
• Previous healthcare or insurance experience including advanced knowledge of Medicare, Medicaid, Marketplace, and other health insurance plans. 
• Excel at managing a high volume of tasks independently.
• FQHC experience preferred but not required.
• Proficiency in knowledge of office management, use of computers, software packages (Microsoft Office), and office machines.

    Physical/Environmental

• Occasional lifting of 40-50 lbs. and pushing of 5-20 lbs.
• Ability to interact with computer screens (visual acuity required)
• Proficiency in knowledge of office management, use of computer, software packages, and office machines
• Must have a medium to high level of manual dexterity for use of keyboard. 
• Ability to remain sitting (approx. 80% of the time), standing and walking, for long periods of time.
• Bending and reaching approximately 20% of the time.
• Strong organizational, planning and time management skills and the ability to self-prioritize work.
• Ability to communicate via phone, mail and in person to resolve disputes, solve problems, etc.
• Capacity to function in a sometimes stressful, multi-tasking environment.
• Normal overtime/extended work hours may be required.
• Normal accessibility and mobility throughout the region.

Blood Borne Pathogen Exposure (Please Check One)

• _____ Category I: Job classification includes ALL employees who have occupational exposure* to bloodborne pathogens* (blood or body fluids) while performing their job duties.
• __X__   Category II:  Job classification includes employees who are likely to have SOME occupational exposure to blood borne pathogens because Category I tasks may occasionally be required.
• _____   Category III:  Job Classification includes those employees who perform jobs and tasks where NO CONTACT with blood borne pathogens occurs, and Category I and Category II tasks ARE NOT a condition of employment.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Work Environment

The work environment characteristics are those for a normal provider office environment. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Work may require occasional weekend and/or evening hours.

Work hours

Full-time or part-time, non-exempt hourly position. Generally, a 40-hour work week is required for full-time; part-time as agreed upon by parties; hours are subject to change. Office hours vary by site, but are usually 8:00am to 7:00 pm, Monday through Friday. Some Saturdays and after business hours work may be required.  Assigned meetings and travel are a part of the position.

Telecommuting may be available at the discretion of the Revenue Cycle Manager and/or CFO or Designee up to 20% routinely in a work week.

Wages

Starting wages for Integrated Health Eligibility and Enrollment Specialist will be negotiable based on Community Health & Wellness Partners of Logan County’s pay policies and factors such as education and experience, national and state average compensation recommendations based on location and region. 

Introductory Period

Ninety (90) calendar days. The successful completion of the introductory period does not alter the at-will employment status.

Equal Opportunity Employer

Community Health and Wellness Partners of Logan County is an Equal Opportunity Employer.