Eligibility Specialist

Scope

Under direct supervision, is responsible for the successful resubmission of invoices to the responsible party. Analyzes and resolves eligibility variances via web research and/or direct contact with patients. Coordinates the activities for the acquisition of referrals and retro-authorizations, where applicable. Follows standard procedures and pre-established guidelines to complete tasks. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards, and US Oncology’s Shared Values.

Essential Duties And Responsibilities

• Researches and obtains accurate and current insurance coverage information, makes corresponding corrections in the PMS.
• Evaluates benefits and eligibility to assess patient financial responsibility.
• Coordinates referral from primary care clinic to ensure appropriate authorizations are secured and entered into the PMS.
• Identifies uninsured patients and refers to patient benefit representative for coordination of payment.
• Communicates system issues and/or payor trends lead or supervisor.
• Answers questions and resolves complaints.
• Documents conversations with payors in the PMS.
• Contacts and follows up with clinic or any missing or incomplete documentation.
• Works TES Edits.
• Researches and responds to routine account inquiries and takes appropriate action; escalates non-routine issues.
• Adheres to confidentiality, state, federal, and HIPAA laws and guidelines with regards to patient’s records and collections.

Minimal Qualifications

• High school diploma or equivalent required.
• Zero to two years with front desk, registrations, healthcare benefits or equivalent experience.
• Proficiency with computer systems and Microsoft Office (Word and Excel) required.

Competencies

• Possesses up to date knowledge of the profession and industry; accesses and uses other expert resources when appropriate.
• Demonstrates Adaptability: Handles day to day work challenges confidently; is willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change; shows resilience in the face of constraints, frustrations, or adversity; demonstrates flexibility.
• Makes timely, cost effective and sound decisions; makes decisions under conditions of uncertainty.
• Sets high standards of performance; pursues aggressive goals and works efficiently to achieve them.
• Emphasizes the need to deliver quality products and/or services; defines standards for quality and evaluated products, processes, and service against those standards; manages quality; improves efficiencies.

Physical Demands

• Sit or stand and talk or hear.
• Full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination.
• Standing and walking for extensive periods of time.
• Lifts and carries items weighing up to 40 lbs.
• Requires corrected vision and hearing to normal range.

Work Environment

• Exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations, and other conditions common to an oncology/hematology clinic environment.
• In-person interaction with co-workers and management and/or clients.
• Minimal travel by automobile to office sites.