Program Eligibility Specialist Job

Full Job Title: Program Eligibility Specialist

Job Number: 17010286

Facility: SSM Health System Office

Location: St. Louis, MO

Schedule: Full Time, Days

Hours: 8:30am - 5:00pm


Role Purpose:
This position is responsible for working Medicaid application follow up, Spend Downs, ESCAN Reports, works all Medicaid add a newborn accounts, and any self pay reports to identify patients who have Medicaid coverage. The PES will assist with the vendor management process, maintain positive relationships with hospital personnel, Patient Business Services personnel and outside agencies in securing optimum benefits for services performed at SSM Health facilities. The PES services all facilities and reports to the System Program Eligibility Supervisor.
    • Analyzes and interprets data from ESCAN reports and Huron tool to ensure accurate invoicing and billing.
    • Analyzes and interprets State Spend Down policy to process Spend Down coverage correctly.
    • Analyzes and interprets Medicaid pending to self-pay report for potential Medicaid coverage.
    • Analyzes and interprets data from vendor inventory to complete reconciliation process.
    • Audits vendor reports and communicate results to vendors and System Program Eligibility Supervisor.
    • Appropriately loads and communicates "found" insurance and active Medicaid prior to patient discharge to Financial Clearance and Utilization Management.
    • Follows up on all Medicaid pending business as per guidelines.
    • Meets or exceed all revenue goals, caseload management goals (i.e. maintaining aged accounts at a designated %) and patient expectations as a team of professional individuals.
    • Drops claims on all approved Medicaid cases and insurance found post discharge.
    • Performs all Insurance Management functions correctly (e.g. ensure Medicaid Pending Plan is added when patient is eligible and removed when the patient is either approved or denied) to avoid out of balance accounts.
    • Ensures all State time frames are met regarding timeliness of newborn reporting submission and Medicaid applications.
    • Adjusts workload to achieve efficiency on a daily basis.
    • Assists with training of new staff.
    • Works with on-site Patient Financial Advocate (PFA) to secure all appropriate documents from patients and third parties.
    Minimum Requirements:
    • High School Diploma required
    • Knowledgeable in the hospital revenue cycle and Medicaid Regulations
    • Experience in working with diverse populations and understanding CMS and state programs assisting consumers with financial obligations
    • Exceptional customer service and compassion for others
    • Working knowledge of spreadsheets and Microsoft Office Suite
    • Possess understanding of regulations outlined by state, federal, and third-party coverage procedures
    Preferred Qualifications:
    • Prefer 3 – 5 years of experience in hospital billing and State Medicaid eligibility

SSM Health - System Office –

SSM Health is one of the largest Catholic health systems in the country and is dedicated to quality and compassionate care for anyone in need, regardless of ability to pay. Based in St. Louis, where its System Office is located, SSM Health operates 20 hospitals in Wisconsin, Illinois, Missouri and Oklahoma. We provide care in various settings: outpatient sites, physician offices, a pharmacy benefit company, an insurance plan, hospitals, nursing homes, home care, hospice, telehealth and a technology company.Our Mission: Through our exceptional health care services, we reveal the healing presence of God.

SSM Health is an Equal Opportunity and Affirmative Action Employer. Qualified applicants are considered for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other characteristic protected by law. Learn More »

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