Eligibility Specialist I - 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 coverageunder the terms of various private and public health care and financial services assistance programs. Thismay include programs such as Medicare, Medi-Cal, Breast and Cervical Cancer diagnostic and treatmentprograms, Managed Care Plans, Medi-Cal Managed Care Programs, private insurance and numerous otherhealth plans and programs; and other related duties as required. ES I are located in the Patient BusinessServices Department at Highland Hospital Emergency, Admitting and Outpatient Registration Departments,Fairmont Hospital Outpatient Registration and Admitting Department and in the Ambulatory Care ServicesDepartments 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 ofsatisfactory performance an evaluation of the full scope of duties is upgraded to an ES II. Performs relatedduties 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, copaymentsand pre-payments for services.

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

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

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

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

6. Immediately updates all patient financial information in the hospital/clinic informationsystem and enrolls all applications and supporting documentation to the appropriateagencies and/or departments within prescribed timelines, to ensure timely andaccurate submission of claims needed to maximize reimbursement to the MedicalCenter.

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

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

9. Plans, organizes and prioritizes workload and processes information at a speednecessary 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 informationnecessary for patient identification, billing and collection of accounts.

12. Reviews and investigates health care coverage and policy limitations to update patientinformation 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 Healthand Disability Program (CHDP), ADAP, and all other related programs.

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

14. Stays informed of both internal and external programs. Researches, reviews,interprets, and follows all relevant policies, procedures, regulations, guidelines andlaws 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 examinationoffered 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 fulltimeclerical experience which must have included at least one year of experience in a hospital/clinic orrelated unit involving determination of eligible or credit and collection work for medical assistance throughpersonal interview or increasingly responsible public contact experience which involved processing financialor personal/confidential information, preferably in a medical/hospital setting. (Candidates hired externally: willneed to successfully complete Eligibility Academy/Training Program within timeframe determined bysupervisor/designee.)