EMPLOYEE

JOB DESCRIPTION AND

PERFORMANCE  EVALUATION

Employee Name:

Date:

Position Title:

Eligibility Clerk IV

Department:

Patient Billing / Eligibility

Manager:

Patient Business Office Manager

Reviewing Period Of

Standard

Defined By

Always

Frequent

In

Frequent

Never

SERVICE

-Responds to customer needs, regardless.

Makes immediate eye contact, acknowledge other with a smile.

Makes a “positive first impression” a top priority.

Responds to difficult situations with self control and a positive attitude.

Demonstrates “service recovery” behaviors, as appropriate.

Makes sure others are satisfied with results.

PERFORMANCE

-Achieves excellence.

Exceeds expectations of supervisor, co-workers, and patients.

Displays sensitivity to any inconvenience others may encounter.

Shows appreciation by saying “thank you.”

Makes “excellence” the goal in all endeavors.

Ensures a safe environment for all others.

INTEGRITY

-Lives the values and Mission Statement.

Separates “personal” issues from work.

Respects, honors & demonstrates confidentiality of patient information.  HIPAA

Does not talk of job related issues to or in front of patients and others.

Displays and encourages a positive image and attitude.

Demonstrates neat appearance and appropriate dress, wears ID badge.

RESPECT

-Honors all individuals.

Listens first, does not jump to conclusions or pre-judge situation.

Acknowledges the perception of others.

Appreciates and respects differences in opinions and approaches.

Acknowledges customer immediately. Make’s them feel welcome.

Knocks on doors before entering. Fully explains intentions to others.

INNOVATION

-Improves constantly.

Strives to turn a negative situation into a positive outcome.

When doesn’t know the answer, find’s someone who does.

Accepts change and contributes to the change effort.

Effectively utilizes resources to minimize costs.

When assigned work is complete, seeks additional tasks.

TEAMWORK

-Trusts and cooperates.

Communicates effectively and courteously.

Takes the initiative to help others.

Treats all staff as members of one cohesive team.

Holds each other accountable for the success of the team.

Respects team by being at work on time and demonstrating regular attendance.

SECTION “A” TOTAL

TITLE:

Eligibility Clerk IV

FLSA STATUS:

Non-Exempt

DEPARTMENT:

Patient Billing / Eligibility

REVIEW DATE:

REPORTS TO:

Patient Business Office Manager

Works under general supervision performing complex duties following established procedures.  Responsible for initiating patient intake process for eligibility of services; serves as patient advocate.  Serves as liaison between IHCRC and Insurance/Managed Care Companies and State of Oklahoma health care programs, with primary emphasis on SoonerCare enrollment; the processing of eligibility for the OB clinic; and Medicaid/Medicare/private insurance verifications, prior-authorizations, referrals, as well as eligibility for prior authorizations, referrals, home health equipment, and other various health care needs.

RESPONSIBILITY

Always

Frequent

In

Frequent

Never

1.

Obtains information to add newborns to medical cases.

2.

Researches all required correspondence as per requested from providers, HMO plans and vendors.

3.

Serves as prior authorization and referral specialist to verify eligibility, submit request for prior authorizations and referrals for Medicaid, Medicare, Private and Managed Care Companies, sets appointments, orders home health equipment, tests, etc.  

4.

Assist patients in social services and resources, CDIB and Tribal verification and benefits.

5.

Keep legible records for reporting and recording of eligible benefits, as well as document status of applications in patient accounts.

6.

Knowledgeable of Medicaid/Medicare eligibility requirements in order to determine patient’s qualifications for various Medicaid programs.  Informs patients of information needed to complete the Medicaid application.  Assist patients with the effective utilization of resources. 

7.

Utilizes updates on a continual basis on the changes that take place resulting in eligibility requirements on State of Oklahoma Programs, especially Medicaid/Medicare. 

8.

Add payer codes, research and updates in Health Pro for various Medicaid programs.

9.

Prepares all required IHCRC monthly reports.

10.

Complies with all AAAHC standards and requirements such as annual TB test, CPR and CEU if applicable.

11.

Interacts and communicates with fellow staff in a way that promotes a harmonious and cooperative working environment.

12.

Complies with all safety rules and regulations. Follows proper safety procedures and utilizes proper protective equipment at all times.

13.

Displays strong written and oral communication skills.

14.

Exhibits maturity and the ability to deal effectively and professionally with patients and staff.

15.

Displays a “customer first” approach to problem solving.

16.

Maintains current knowledge of, and participates in, compliance efforts associated with the Government Performance Results Act (GPRA).  Captures data as appropriate.

17.

Performs other duties as assigned.

SECTION “B” TOTAL

Knowledge, Skills, Abilities

High school graduate or equivalent.  Two years college courses.  2+ years experience in work as a Case Manager, eligibility worker, social worker in a medical environment.

CPR certification.

Intermediate computer skills.  Proficient in MS Office and/or additional applicable software programs.

Ability to demonstrate a special understanding of Indian culture. Familiarity with Native American health care trends.

Strong written and oral communication skills.  Excellent interpersonal skills.

Ability to multi-task and work independently, demonstrating initiative and accuracy in work results.

Working Conditions

Mostly sedentary.  Must be able to sit in a chair most of the day to do the work.  Must be able to maneuver the body while sitting and using a computer keyboard. Minimal standing, walking, bending, carrying of light items (up to 15 pounds) such as papers, books, files, and lifting of mail baskets and office items.

ACCOMPLISHMENTS:

AREAS NEEDING IMPROVEMENT:

GOAL’S FOR UPCOMING YEAR: