Medical Eligibility Specialist (CC0707 - East)

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.
• 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.
• Investigates and resolves 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.
• 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.

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