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Duke University Health System · 1 month ago

Medicaid Eligibility Analyst

Durham, NC

Full-time

Hybrid

Mid Level

4+ years exp

Duke University Health System is committed to compassionate care and is seeking a Medicaid Eligibility Analyst to support their Patient Revenue Management Organization. The role involves coordinating the Medicaid application process to obtain eligibility for patients and ensuring compliance with federal regulations while maximizing reimbursement for services provided.

Health CareMedical

Responsibilities

Conduct thorough, in-depth interviews and evaluate patient's case for potential eligibility for Medical Assistance Programs and any applicable Purchase of Medical Care programs

Analysis of patient's assets, income, clinical history, and dependent responsibilities, must be conducted in a precise manner based on knowledge and interpretation of the federal regulations and Social Security Administration guidelines

Assess patient's continuing care needs and determine correct program and certification period to minimize patient deductible and maximize entity reimbursement

Communicate and advise patients on complex financial concepts and procedures of applying for Medicaid

In some cases, may act as the authorized patient's representative for the purpose of initiating an application for benefits and for conducting any and all activities associated with determination of eligibility of benefits, including the initiation and conduct of administrative and /or judicial appeals

There is legal liability involved for the Medicaid Eligibility Analyst, as they are responsible to the county/state for the accuracy of information and actions taken on behalf of the patient

The Medicaid Eligibility Analyst has the ability to act for the individual and exercise the individual's rights

Coordinate and facilitate the completion of the Medicaid application

Gather and provide necessary verifications to establish Medicaid eligibility via direct contact with patient and/or patient's family, employer, financial institution, vital statistics and other collaterals to the County Department of Social Services Income Maintenance Caseworker in the county of patient residency

Follow-up with patient and the Department of Social Services to ensure all pertinent information has been provided relevant to the Medicaid application

This may require travel to county of patient residency for the purpose of transporting the patient to the Department of Social services for follow-up visits, obtaining additional records, and verifying or correcting information on behalf of the patient

Anticipate and troubleshoot logistic and compliance barriers

Evaluate case files to determine issues and sufficiency of evidence or documentation, analyzing Social Security Administration rules, Division of Medical Assistance guidelines and relevant regulations for applicability

Initiate fact finding, research in support or denial of case merit

Based on findings, evaluate if challenge is appropriate and facilitate the request for a hearing from the responsible local agency or State Office of Hearings and Appeals if warranted

Prepare hearing briefs, assemble documentary evidence and exhibits to represent the patient at local agency, State and Chief Hearing Officer hearings for the purpose of reversing a negative decision with or without the patient's assistance

Interview, evaluate and prepare potential witnesses for substantive evidence in support of the decision reversal

Present patient case, examine and cross examine witness, and enter evidence into the case file at adjudication hearings to establish patient's eligibility for Medicaid

Responsible for entering pertinent information into the hospital system and closely monitoring authorization dates and deductible amounts applied to patient accounts

Reconcile account financial status coding monthly to ensure accounts are represented accurately

Serve as an educational resource on Medicaid issues for patients, Social Workers, Physicians, Clinic and Admissions personnel

Review and monitor revisions in policy/regulations for all Medicaid programs on a regular basis to determine the effect of these revisions on pending applications

Perform other related duties incidental to the work described herein

Qualification

Medicaid application processFederal regulations knowledgeSocial Security Administration guidelinesBilingualCommunication skillsProblem-solvingAdaptabilityTeam collaborationNegotiation skills

Required

Bachelor's degree in business, healthcare administration, accounting, finance or a related field is required

Four years of related experience is required

Excellent communication skills, oral and written

Managing sense of complex, high quantity, and sometimes contradictory information to effectively solve problems, while making good and timely decisions that keep the organization moving forward

Ability to actively learn when facing new situations, adapt quickly and positively to change, perform multiple tasks and work independently

Must be able to work collaboratively with others to meet shared objectives while maintaining professional, service-oriented working relationships with key stakeholders such as patients, physicians, case managers/social workers, co-workers, supervisors, and representatives at Department of Social Services/Department of Disability Services

Shares own ideas/viewpoint in a compelling manner and negotiates skillfully when working toward an agreed solution or common goal

Ability to engage with individuals in their feeling, capabilities, and perspectives in order to best meet and anticipate their needs

Collaborate with others to promote cooperation and commitment within a team to achieve goals and deliverables

Must be able to understand, interpret, and comply with Duke Health and Medicaid policies and procedures