Eligibility Specialist I

Alameda Health System•Oakland, CA

About The Position

Under general supervision, the Eligibility Specialist I performs hospital admitting, discharge, registration, and financial screening functions to determine eligibility for medical coverage through private and public health care and financial assistance programs. These may include Medicare, Medi-Cal, cancer diagnostic and treatment programs, managed care plans, private insurance, and other health plans and programs. The role is based in Patient Business Services at Highland Hospital, Fairmont Hospital, or Ambulatory Care Services clinics; staff may be required to work at alternate locations as needed. This classification is flexibly staffed. New employees are hired as Eligibility Specialist I, and after 12 months of satisfactory performance, their full scope of duties is evaluated for upgrade to Eligibility Specialist II. Externally hired candidates must successfully complete the Eligibility Academy/Training Program within the timeframe set by their supervisor or designee. The role also performs related duties as required.

Requirements

High school diploma or equivalent.
Successful completion of the Eligibility Academy/Training Program and its examination offered through Alameda Health System.
Demonstrated use of a PC and related applications.
Either one year in the Eligibility Clerk classification, or the equivalent of two years of full-time clerical experience.
The qualifying clerical experience must include at least one year in a hospital, clinic, or related unit involving eligibility determination or credit and collection work for medical assistance through personal interview, or increasingly responsible public-contact experience involving financial or personal/confidential information.
Externally hired candidates must complete the Eligibility Academy/Training Program within the timeframe determined by the supervisor or designee.

Nice To Haves

Bilingual ability where necessary.
Experience in a medical or hospital setting.

Responsibilities

Advise patients or guarantors of financial obligations and collect and process deposits, copayments, and prepayments.
Help patients resolve hospital-account billing and collection issues by reviewing account information and payment history, verifying insurance or other coverage, obtaining needed information, and arranging payments.
Assist with special projects and perform related clerical and administrative duties.
Contact and consult with patients, guarantors, representatives, and outside agencies about matters related to eligibility for health care services.
Determine eligibility for third-party payment sources, including private health plans, Victims of Crimes, Workers’ Compensation, and lawsuit settlements.
Update patient financial information in hospital or clinic systems and submit applications and supporting documents to the appropriate agencies or departments within prescribed timelines.
Inform medical providers of patients’ financial status and communicate with physicians and clinical staff about health conditions or diagnoses that may qualify patients for assistance programs.
Interpret applicable laws and regulations and advise patients about program eligibility requirements, rights, and obligations; assist with applications and forms and review them for accuracy and completeness.
Plan, organize, and prioritize workload and process information at a pace required for successful job performance.
Train Eligibility Clerks and Eligibility Specialists I/II in registration and eligibility procedures.
Register and interview patients to obtain demographic and financial information for identification, billing, and collections.
Review and investigate health care coverage and policy limitations and update patient information for long-term care, short-term treatment, and assistance programs.
Discuss difficult or unusual cases with a supervisor or lead worker to clarify and ensure accurate assessments of patient finances and eligibility.
Stay informed about internal and external programs; research, interpret, and follow relevant policies, procedures, regulations, guidelines, and laws; and attend mandatory training.