Eligibility Specialist

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Key/Essential Functions & 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.

Minimum Qualification Requirements including education, experience, licensure/certification, etc. and essential physical capabilities (e.g. lifting, assisting lifting, standing, etc.)

* High School diploma or its educational equivalent; and

* 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…