Medicaid/Medical Benefits Eligibility Outreach Specialist
Full Time
Bowler, WI 54416
Posted
Job description
GENERAL RESPONSIBILITIES: To assist patients with applying for and obtaining coverage for medical services through alternate sources available to them. To oversee the day to day operation of tracking payments and paying premiums for tribal members who are eligible for contract health services. This position is under the direct supervision of the PRC Manager.
DUTIES:
- Provides leadership and acts as an advocate to patients to assist in effectively applying for and utilizing Medicaid and related alternate medical resources such as Medicare, VA, Group Health/Private insurance, and Marketplace insurance.
- Interprets Federal, Tribal, and state rules and regulations following explicit guidelines in order to determine patient eligibility for various referral health services.
- Works closely with Tribal Social Services and other Tribal agencies, appropriate local County Department, HMO’s private insurers, etc., to establish and to verify eligibility for alternate resources.
- Develops and implements effective screening, outreach and interviewing methods to assure maximum identification of individuals who have or are eligible for alternate medical resources.
- Attempts to find individuals in need who have lost eligibility but whom may be eligible, and individuals who have not applied for coverage but may be eligible. Also works with Patient Registration/Receptionist staff and with Contract Health Services personnel to find individuals who might benefit from alternate resource options.
- Assists families and individuals in application for and use of alternate resources. Makes home visits if needed as assists with applications, providing transportation and interpretation of rules and regulations.
- Performs a variety of Patient Representative functions such as making home/hospital visits to interview and assist patients with Medicaid, Medicare, or insurance applications.
- Maintains communication as needed with State Enrollment Contractor and State Enrollment Monitoring personnel, beginning with attendance at training by Medicaid Enrollment and/or State personnel.
- Maintains current knowledge of pertinent changes in rules and regulations for alternate resources, including any changes in Medicaid Managed Care (state Medicaid programs) procedures that may result from the new non-mandatory enrollment legislation. (new Affordable Care Act legislation)
- Supports and adheres to established policies and procedures endorsed by the Tribal site.
- Assist in implementation of potential changes to policy, procedure, and payment process for long term needs.
- Responsible for monitoring and reporting financials for this program.
- To ensure tribal members who are applying for the TPSP have up to date eligibility documentation on file in the CHS program.
- Assist tribal members in answering questions and concerns pertaining to the Marketplace.
- Ensure TBSP policies, processes, and guidelines are being adhered to.
- Track, document, and monitor information and verification of income for each participant to identify drops in coverage or changes in coverage.
- Maintain a detailed data base for reporting purposes.
- Track, document, and monitor invoices and statements for accuracy in payment of premiums.
- Work closely with Case Manager to identify high cost cases and distinguishing time frame for insurance coverage directly related to medical services that are being referred.
- Ability to understand rules and regulations of Medicare, Medicaid, Marketplace insurance, etc.
- Must maintain an acceptable departmental attendance record.
- Must be reliable and prompt when reporting to work.
- Required to attend job related, in-service, meetings, and training to maintain professional and technical knowledge.
- Must adhere to tribal law and other applicable laws as well as tribal personnel policies and procedures.
- May be required to satisfactorily complete an exam or other testing requirement(s) to determine skill proficiency.
- The above duties and responsibilities are not an all inclusive list but rather a general representation of the duties and responsibilities associated with this position. The duties and responsibilities will be subject to change based on organizational needs and/or deemed necessary by the supervisor.
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