Eligibility Specialist

The Eligibility Specialist obtains initial information relating to admissions, coordinates intake process, and provides information and referrals to community agencies. Supports enrollment team with eligibility. Promotes the Senior CommUnity Care Program to potential participants and community agencies.

QUALIFICATIONS:

• Bachelor's degree in a health and human services field or equivalent years of experience related to public benefits.
• Two (2) years of experience in marketing, with more emphasis on sales, and/or admissions role for a health care provider, or in an information and referral resource role within the senior networks. Shall have either training or related experience in the job assigned.
• Have a minimum of one year of experience in working with the frail or elderly population.
• Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
• Must have a valid driver's license and have means of transportation within one hundred (100) miles or more daily.
• Must clear background check.

Skills and Knowledge:

• Ability to effectively present PACE philosophy and model to the community and to prospective participants.
• Working knowledge of the communities' health and social service delivery system, and aging network.
• Effective written and verbal communication skills.
• Ability to learn, comprehend and stay current of Medicaid system.
  General knowledge of financing mechanisms such as Medicaid, Medicare, Prospective Payment Systems and Health Maintenance Organization/Managed Care providing risk-based capitated systems.
• Good working knowledge of PACE philosophy and eligibility/denial criteria.
• Ability to work under pressure of monthly deadlines; to be able to remain focused while gathering last minute information, appointments, information for Medicaid, IDT and families in order to meet enrollment goals.
• Ability to utilize computers and other electronic devices for tasks such as timekeeping, in-servicing and documentation.
• Only acts within the scope of his or her authority to practice. Must meet a standardized set of competencies for the specific position description established by Senior CommUnity Care and approved by CMS before working independently.

ESSENTIAL FUNCTIONS:

• In collaboration with Enrollment Specialist, gather necessary documentation and application requirements in working with participants for Medicaid approval.
• Ensures compliance with all State Medicaid Rules and Regulations that pertain to Medicaid, Straight Medicaid, LTC, Spousal Impoverishment and Trusts, Food Stamps, Old Age Pension (OAP) and other Medicaid programs for which participants may be eligible.
• Tracking private pay clients and instrumental in obtaining a smooth transition to Medicaid eligibility.
• Guides participants through financial eligibility process.
• Interpret program regulations and other pertinent material to applicants, recipients, and the general public.
• Reviews Medicaid eligibility monitors time frame for re-certification and facilitates Medicaid applications for certification and re-certification.
• Collects data and prepares reports in accordance with Centers for Medicare and Medicaid Services (CMS) requirements or program requirements.
• Maintain ongoing relationships with identified individuals and agencies to ensure a clear understanding of the program as a vital community resource. Promote strong relationship with Counties in regard to eligibility, participant contact information, disenrollment and any other necessary participation information.
• Maintain a focus on meeting the needs of internal and external customers; develop and maintain effective relationships with others; relate well to people from varied backgrounds and in different situations; show understanding, courtesy, tact, empathy, concern, and politeness.
• Obtain necessary information during phone and in-person interviews by establishing rapport, explaining the purpose of the interview, responding to customer concerns/questions, and/or asking appropriate follow-up questions.
• Write information, using accurate grammar, in a manner that is clear, well-organized, and follows a logical progression to ensure the writing is tailored to the intended audience or purpose.
• Use data and statistics to analyze and draw reasonable conclusions and compile accurate reports and records.
• Assist Enrollment Specialist in receiving and providing information to referrals to the Senior CommUnity Care Program; refers individuals to other appropriate resources as indicated.
• Assesses potential participants in home, nursing homes, hospitals or other settings as part of the intake process.
• Maintains current, written assessment and intake records inclusive of potential participant's expressed wishes and the referral services provided, as appropriate.
•  Assists potential participants in managing their needs while undergoing intake and assessment process, including referrals to doctors and other community agencies.
• Participates in Interdisciplinary Team meetings when potential enrollees are assessed for enrollment into the program for purposes of providing and clarifying information obtained during the intake assessment.
• Provides alternative community resources to applicants who are not accepted into the program.
• Is responsible for reviewing and assuring that the enrollee understands the enrollment agreement material presented. Is responsible for reviewing participant's rights and responsibilities and assuring that the participant and/or authorized representative understand these rights.
• Reviews Medicaid eligibility monitors time frame for re-certification and facilitates Medicaid applications for certification and re-certification.
• Collects data and prepares reports in accordance with Centers for Medicare and Medicaid Services (CMS) requirements or program requirements.
• Assists in evaluating the intake and assessment process, identifying problem areas accordingly and making changes as recommended.
• Contacts identified key referral sources regularly to discuss possible program candidates.
• Maintain ongoing relationships with identified individuals and agencies to ensure a clear understanding of the program as a vital community resource.
• Participants and supports the Quality Improvement Initiatives.
• Practices Universal Precautions and follows appropriate infection control procedures.
• Provides information and referrals as appropriate to community advocates or elder law attorney.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
• Ability to be cognizant of their surroundings and make immediate assessment of potentially unsafe environments and act accordingly.
• Ability to keep accurate and detailed records and data.
• Performs related duties as required or requested.