Eligibility Specialist I [830am-500pm] - EASTMONT - Alameda Health System

Job Summary: Under general supervision, the Eligibility Specialist I (ES I) performs a variety of hospital admitting, discharge, registration and financial screening functions, with the objective of determining eligibility for medical coverage under the terms of various private and public health care and financial services assistance programs. This may include programs such as Medicare, Medi-Cal, Breast and Cervical Cancer diagnostic and treatment programs, Managed Care Plans, Medi-Cal Managed Care Programs, private insurance and numerous other health plans and programs; and other related duties as required. ES I are located in the Patient Business Services Department at Highland Hospital Emergency, Admitting and Outpatient Registration Departments, Fairmont Hospital Outpatient Registration and Admitting Department and in the Ambulatory Care Services Departments at the freestanding Clinics. Staff may be required to work at alternate locations as necessary. This classification series is flexibly staffed wherein a new employee is hired as an ES I and after 12 months of satisfactory performance an evaluation of the full scope of duties is upgraded to an ES II. Performs related duties as required.

DUTIES & ESSENTIAL JOB FUNCTIONS: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Advises patient/guarantor of financial obligations; collects and processes deposits, co-payments and pre-payments for services.

2. Assists patients in resolving issues with billing and collection of their hospital account(s). Reviews and analyzes patient account information, payment history, verification and collection of insurance or other coverage information and/or assists patient in submitting needed information to billing or setting up payment arrangements.

3. Assists with special projects and performs related clerical and administrative duties as required.

4. Contacts and consults with patient, guarantor, or other representative, as well as with various County, State, Federal or other outside agencies regarding patient matters related to eligibility for health care services.

5. Determines eligibility for a third party payment source according to established policies and procedures including private health plans, Victims of Crimes, Workers’ Compensation and lawsuit settlements.

6. Immediately updates all patient financial information in the hospital/clinic information system and enrolls all applications and supporting documentation to the appropriate agencies and/or departments within prescribed timelines, to ensure timely and accurate submission of claims needed to maximize reimbursement to the Medical Center.

7. Informs and advises medical providers of patients’ financial status and maintains open communication with Physicians and clinical staff to ensure timely notification of any health conditions or diagnosis that could qualify patient for programs to assist them with their healthcare costs.

8. Interprets laws and regulations of Federal, State and County programs and advises patient of eligibility requirements, as well as their rights and obligations in receiving financial services from these programs. Assists patients in completing applications and forms when necessary and reviews for accuracy and completion.

9. Plans, organizes and prioritizes workload and processes information at a speed necessary for successful job performance.

10. Provides training for EC’s, ES I/II’s for the purposes of registration and eligibility.

11. Registers and interviews patients to obtain demographic and financial information necessary for patient identification, billing and collection of accounts.

12. Reviews and investigates health care coverage and policy limitations to update patient information for long term care, short term treatment and/or programs such as Charity, County Medical Services Program (CMSP), Medi-Cal, Family P.A.C.T., Child Health and Disability Program (CHDP), ADAP, and all other related programs.

13. Reviews difficult or unusual cases with Supervisor or Lead Worker for clarification and to ensure accuracy in assessing patient financial circumstances and eligibility determinations.

14. Stays informed of both internal and external programs. Researches, reviews, interprets, and follows all relevant policies, procedures, regulations, guidelines and laws and attends mandatory trainings. Works independently with minimal supervision.

Qualifications

Education: High School diploma or equivalent.

Education: Successful completion of the Eligibility Academy/Training Programs and respective examination offered through AHS.

Minimum Experience: Bilingual, where necessary.

Minimum Experience: Demonstrated use of PC and related applications.

Minimum Experience: One-year in the classification of Eligibility Clerk, OR The equivalent of two years fulltime clerical experience which must have included at least one year of experience in a hospital/clinic or related unit involving determination of eligible or credit and collection work for medical assistance through personal interview or increasingly responsible public contact experience which involved processing financial or personal/confidential information, preferably in a medical/hospital setting. (Candidates hired externally: will need to successfully complete Eligibility Academy/Training Program within timeframe determined by supervisor/designee.)

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