Eligibility Specialist

YAI•New York, NY

11d•Onsite

About The Position

The Eligibility Specialist will be responsible for reviewing Medicaid rejections and proactively identifying eligibility issues. This role involves compiling information, making notifications for corrective action to support billing and maximize reimbursement, and submitting documentation or applications to government agencies. The specialist will also alert Care Coordination Organizations (CCOs) of coverage lapses and advise on spenddown processing. They will respond to requests from government agencies and denials of entitlements by gathering necessary documentation to establish, maintain, or expand benefit entitlements for individuals in the assigned region. This includes completing and submitting forms and applications on behalf of individuals for benefits like Medicaid, Social Security, and food stamps. The role requires coordination with CCOs and other provider agencies to obtain eligibility information and reestablish eligibility for individuals receiving community or other non-residential YAI services. Tracking spenddown payments, collaborating with program leadership and the Department of Finance/DARB Unit, and assisting with eligibility-related questions are also key responsibilities. The specialist will maintain documentation, track application status, and escalate concerns to their supervisor. They will also complete and submit reports, such as quarterly Representative Payee reports to the Social Security Administration. Collaboration with the finance team on eligibility matters, including billing issues and external coordination, is expected. Regular updates to finance staff and escalation of concerns to the supervisor are required. The role involves assisting the Director of Revenue Management with data and document gathering for audits and reviews. Establishing contacts with government agencies like OPWDD, Veterans Administration, and Local Medicaid offices is crucial for continuous eligibility. Additionally, the specialist will perform various clerical, administrative, and financial tasks to support the revenue management department, including filing, copying, scanning, data entry, document creation, and mail sorting. Compliance with all Federal, State, Local, and regulatory agency requirements, including HIPAA, is mandatory. Performs all other duties, as assigned.

Requirements

High School diploma or its educational equivalent
Two (2) years of experience working with the I/DD population or related experience in human or social services and/or healthcare, which includes assisting people in applying for services and/or exposure to benefits or entitlements; or Satisfactory equivalent combination of education, experience and/or training.
Familiarity with benefits and entitlements in the healthcare and/or I/DD field including Medicaid, Medicare, Social Security and applicable regulatory agencies.
Strong written and oral communication skills, including the ability to effectively obtain and communicate information with staff at varying levels.
Detail oriented and highly organized with good time management and follow-up skills, including the ability to effectively track and accurately compile data.
Ability to work autonomously and work well in groups, including building relationships and working collaboratively with other finance staff.
Proficiency with computers and ability to quickly learn electronic systems including Digital Agency (DA), electronic health record, ePACES, Workday and working knowledge of Microsoft Office applications, specifically Excel and Word.
Ability to meet essential physical demands of position including: using hands to finger, handle or feel objects, tools or controls; sitting, standing, bending, twisting and reaching with hands and arms.

Nice To Haves

Previous experience with medical billing and systems, specifically billing for services received by individuals with I/DD in assigned state of operations (NY or NJ)
Previous experience processing or completing applications for Medicaid and Social Security benefits or entitlements.

Responsibilities

Regularly reviews Medicaid rejections and/or proactively identifies eligibility issues for review and compiles information or makes notifications to facilitate corrective action to support billing and maximize reimbursement for services including submitting documentation or applications to government agencies, alerting Care Coordination Organizations (CCOs) of lapses in coverage and advising of spenddown not being paid/processed.
Reviews and responds to requests from government agencies and/or denials of entitlements by obtaining and compiling required documentation from electronic systems, program staff or other sources to establish, maintain or expand benefit entitlements for persons supported in assigned region and/or area(s).
Completes forms and applications on behalf of persons supported and submits to applicable agencies to secure or continue benefits for which they are eligible (Medicaid, Social Security, food stamps, etc.).
Coordinates with CCOs and other provider agencies to obtain eligibility information and/or to secure or reestablish eligibility for people we support receiving community or other non-residential YAI services, which may include obtaining information from electronic systems and collaborating with OPWDD and/or Medicaid.
Tracks submission of spenddown payments for people we support in collaboration with program leadership, working with the Department of Finance/DARB Unit, if needed, to ensure timely processing or to address issues or concerns.
Collaborates with program leadership to obtain information, documentation and/or updates or to complete applications or recertifications needed to support continuation of or to secure additional entitlements, such as food stamps, to ensure that we are maximizing benefits received by the people we support and assists with eligibility-related questions.
Maintains documentation for eligibility-related requests and submissions, including scanning, saving and uploading physical documentation submitted to various agencies or programs in applicable electronic systems or other files.
Tracks status of applications and escalates concerns or delays to supervisor for handling and follow-up.
Completes and submits reports, as requested or to satisfy regulatory requirements, including quarterly Representative Payee reports to Social Security Administration for all people we serve as representative payee for.
Collaborates with other members of finance team for eligibility-related matters, which may include identifying and assisting with resolutions to billing issues and coordinating with external parties if/as needed, checking eligibility in applicable electronic systems, preparing and distributing reports or statements.
Provides regular updates to other finance department staff and escalates eligibility, state or other agency concerns or issues and inefficiencies to supervisor for handling.
Assists Director of Revenue Management with gathering data and documents for requests by Quality and Compliance department and/or for any other program or financial audit or review.
Establishes contacts with various government agencies including Office for People with Developmental Disabilities (OPWDD), Veterans Administration, Local Medicaid offices, etc. to facilitate continuous eligibility and/or timely updates to eligibility for the people we support.
Performs a variety of clerical, administrative and financial tasks to support revenue management department as requested including, but not limited to filing, copying, scanning and/or data entry; creating memos, lists, spreadsheets or other documents; receiving and sorting mail and/or making notifications or inquires by email or phone.
Complies with all Federal, State, Local and other relevant regulatory agency requirements, including the Health Insurance Portability and Accountability Act (HIPAA) and ensures cooperation with appropriate entities in any inspection, inquiry or investigation.
Performs all other duties, as assigned.