Eligibility Specialist I
Company: Alameda Health System
Posted on: January 10, 2022
Job Summary: Under general supervision, the Eligibility Specialist
I (ES I) performs a variety of hospital admitting, discharge,
registration and financial screening functions, with the objective
of determining eligibility for medical coverage under the terms of
various private and public health care and financial services
assistance programs. This may include programs such as Medicare,
Medi-Cal, Breast and Cervical Cancer diagnostic and treatment
programs, Managed Care Plans, Medi-Cal Managed Care Programs,
private insurance and numerous other health plans and programs; and
other related duties as required. ES I are located in the Patient
Business Services Department at Highland Hospital Emergency,
Admitting and Outpatient Registration Departments, Fairmont
Hospital Outpatient Registration and Admitting Department and in
the Ambulatory Care Services Departments at the freestanding
Clinics. Staff may be required to work at alternate locations as
necessary. This classification series is flexibly staffed wherein a
new employee is hired as an ES I and after 12 months of
satisfactory performance an evaluation of the full scope of duties
is upgraded to an ES II. Performs related duties as required.
DUTIES & ESSENTIAL JOB FUNCTIONS: The following are the duties
performed by employees in this classification. However, employees
may perform other related duties at an equivalent level. Not all
duties listed are necessarily performed by each individual in the
1. Advises patient/guarantor of financial obligations; collects and
processes deposits, co-payment and pre-payments for services.
2. Assists patients in resolving issues with billing and collection
of their hospital account(s). Reviews and analyzes patient account
information, payment history, verification and collection of
insurance or other coverage information and/or assists patient in
submitting needed information to billing or setting up payment
3. Assists with special projects and performs related clerical and
administrative duties as required.
4. Contacts and consults with patient, guarantor, or other
representative, as well as with various County, State, Federal or
other outside agencies regarding patient matters related to
eligibility for health care services.
5. Determines eligibility for a third party payment source
according to established policies and procedures including private
health plans, Victims of Crimes, Workers' Compensation and lawsuit
6. Immediately updates all patient financial information in the
hospital/clinic information system and enrolls all applications and
supporting documentation to the appropriate agencies and/or
departments within prescribed timelines, to ensure timely and
accurate submission of claims needed to maximize reimbursement to
the Medical Center.
7. Informs and advises medical providers of patients' financial
status and maintains open communication with Physicians and
clinical staff to ensure timely notification of any health
conditions or diagnosis that could qualify patient for programs to
assist them with their healthcare costs.
8. Interprets laws and regulations of Federal, State and County
programs and advises patient of eligibility requirements, as well
as their rights and obligations in receiving financial services
from these programs. Assists patients in completing applications
and forms when necessary and reviews for accuracy and
9. Plans, organizes and prioritizes workload and processes
information at a speed necessary for successful job
10. Provides training for EC's, ES I/II's for the purposes of
registration and eligibility.
11. Registers and interviews patients to obtain demographic and
financial information necessary for patient identification, billing
and collection of accounts.
12. Reviews and investigates health care coverage and policy
limitations to update patient information for long term care, short
term treatment and/or programs such as Charity, County Medical
Services Program (CMSP), Medi-Cal, Family P.A.C.T., Child Health
and Disability Program (CHDP), ADAP, and all other related
13. Reviews difficult or unusual cases with Supervisor or Lead
Worker for clarification and to ensure accuracy in assessing
patient financial circumstances and eligibility determinations.
14. Stays informed of both internal and external programs.
Researches, reviews, interprets, and follows all relevant policies,
procedures, regulations, guidelines and laws and attends mandatory
trainings. Works independently with minimal supervision.
Education: High School diploma or equivalent.
Education: Successful completion of the Eligibility
Academy/Training Programs and respective examination offered
Minimum Experience: Bilingual, where necessary.
Minimum Experience: Demonstrated use of PC and related
Minimum Experience: One-year in the classification of Eligibility
Clerk, OR The equivalent of two years fulltime clerical experience
which must have included at least one year of experience in a
hospital/clinic or related unit involving determination of eligible
or credit and collection work for medical assistance through
personal interview or increasingly responsible public contact
experience which involved processing financial or
personal/confidential information, preferably in a medical/hospital
setting. (Candidates hired externally: will need to successfully
complete Eligibility Academy/Training Program within timeframe
determined by supervisor/designee.)
Keywords: Alameda Health System, Oakland , Eligibility Specialist I, Other , Oakland, California
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