Medicaid Eligibility Specialist

Jordan Valley Health•Springfield, MO

18h•Onsite

About The Position

The Medicaid Eligibility Specialist serves as an advanced resource for Medicaid eligibility, enrollment, and case resolution activities. This position is responsible for reviewing complex cases, resolving escalated issues, providing technical guidance to front-line staff, and ensuring compliance with state and federal Medicaid regulations. The Medicaid Eligibility Specialist acts as a subject matter expert and liaison between eligibility staff, managed care organizations, providers, and state agencies to support timely and accurate access to Medicaid benefits. Medicaid Eligibility Specialist typically handle escalated eligibility determinations, renewals, changes, and complex case reviews requiring advanced knowledge of Medicaid policy and procedures.

Requirements

Minimum of three (3) years of experience in Medicaid eligibility, public assistance programs, patient access, insurance enrollment, or related field.
Experience interpreting policies and making independent eligibility determinations.

Nice To Haves

Associate’s degree or relevant certification
Previous experience in an FQHC, community clinic, or safety-net healthcare setting
EPIC, electronic health record experience preferred
Experience addressing social determinants of health.

Responsibilities

Review and process complex Medicaid applications, renewals, and case changes.
Investigate and resolve escalated eligibility issues referred by Tier 1 staff or external stakeholders.
Analyze income, household composition, residency, citizenship, and other eligibility factors to determine Medicaid eligibility.
Complete redeterminations and eligibility corrections within established timeliness standards.
Ensure compliance with all federal, state, and agency policies governing Medicaid eligibility.
Serve as the primary escalation point for complex eligibility and enrollment inquiries.
Research policy questions and provide guidance to Tier 1 staff.
Assist with interpretation and application of Medicaid regulations and policy updates.
Identify system issues and collaborate with technical teams to resolve eligibility-related concerns.
Support quality assurance efforts by reviewing cases and identifying trends or training opportunities.
Respond to escalated member, provider, and community partner inquiries.
Explain Medicaid eligibility decisions, enrollment requirements, and program benefits.
Coordinate with healthcare providers, managed care organizations, and community agencies to facilitate access to services.
Maintain professionalism and confidentiality when handling sensitive information.
Mentor and train Tier 1 staff on eligibility processes and policy changes.
Participate in quality audits and corrective action initiatives.
Assist with development and maintenance of standard operating procedures.
Recommend process improvements to increase efficiency, accuracy, and customer satisfaction.
Maintain accurate electronic case records and supporting documentation.
Utilize eligibility and enrollment systems to document actions and track case activity.
Generate reports and provide data related to workload, timeliness, and quality measures.
Participate in audits and compliance reviews as required.
Assist patients with Medicaid applications, renewals, and changes, including gathering required documentation.
Determine and issue Presumptive Eligibility for Medicaid in compliance with state and federal guidelines.
Clearly explain eligibility determinations, coverage timelines, and next steps to patients.
Track and follow up on applications to ensure continuity of care and coverage.
Promote effective working relations and work as part of a team to facilitate the organization’s ability to meet its goals and objectives.
Attain all agreed-upon goals and objectives within specified time frames, contributing to the organization’s overall mission.
Consistently meet monthly individual productivity goals and key performance indicators (KPIs) as determined by Management.
Maintain accurate, timely documentation in the electronic health record (EHR) and eligibility systems.
Ensure compliance with HRSA, Medicaid, and FQHC regulatory requirements.
Protect patient confidentiality and comply with HIPAA and organizational privacy policies.
Participate in internal audits, quality assurance activities, and compliance reviews as required.
Stay current on changes to Medicaid, Presumptive Eligibility, and Sliding Fee Scale regulations.
Responsibly follow the Clinic Exposure Control Plans, including protocols for Bloodborne and Airborne Pathogens.
Demonstrate respect and regard for the dignity of all patients, families, visitors, and fellow employees to maintain a professional, responsible, and courteous environment.
Provide metrics if needed to meet various GRANT funded initiatives
Maintain established productivity and timeliness standards.
Achieve quality review scores of 95% or higher.
Resolve escalated cases within established service-level agreements.
Demonstrate expertise in Medicaid policy and serve as a resource to staff and stakeholders.
Support agency goals related to access, enrollment accuracy, and customer satisfaction.
Collaborate with registration, billing, care teams, case management, and leadership to support patient access.
Refer patients to internal programs and external community resources, including housing, food assistance, transportation, and social services.
Participate in outreach events, enrollment activities, and community engagement efforts as needed.
All other duties as assigned.

Benefits

Medical and Prescription Drug Coverage: Three comprehensive plan options (Buy-up, Base, and High Deductible) through UnitedHealthcare's Choice Plus network, covering various deductibles and out-of-pocket limits. Includes access to telemedicine services via Teladoc.
Health Savings Account (HSA): Available for employees in the High Deductible Plan with employer contributions and tax advantages.
Flexible Spending Account (FSA): Options for both healthcare and dependent care FSAs, allowing pre-tax contributions for qualified expenses.
Dental and Vision Coverage: Dental insurance through Cigna’s DPPO network and vision coverage through EyeMed’s Insight network.
Retirement Plan: Pre-tax and Roth 403(b) retirement plans with a 5% employer match starting after 30 days of employment.
Life and Disability Insurance: Basic Life and AD&D insurance provided at no cost, with the option to purchase additional coverage. Long-term and short-term disability insurance are also available.
Employee Assistance Program (EAP): Free confidential support for personal and professional challenges, including counseling and crisis intervention.
Additional Voluntary Benefits: Options for critical illness, accident, hospital care, and pet insurance through MetLife.
Pay on Demand Available
Holidays: Nine paid holidays per year.
Health Requirements: All employees are required to provide proof of vaccination for Flu, Hepatitis B and Tuberculosis (TB) as part of our commitment to maintaining a safe and healthy workplace.