Medicaid Coordinator

Primary Function Assist patients that are receiving or getting ready to receive Medicare with completing applications and obtaining necessary coverage. Coordinate with CIHA Pharmacy for patient Part D coverage, and EBCI PHHS for Part B coverage. Perform at a progressive level of technical and specialized functions for the Cherokee Indian Hospital Authority. This position will serve as a great resource to CIHA and the community. Provide education on the functions and purpose of the program for patient care. Work closely with patients, medical staff, and the managers of Patient Access, Member Services, Purchased Referred Care (PRC), Public Health and Human Services (PHHS) and the Revenue Cycle Office. Create and maintain tracking and enrollment records (physical files and on the computer). Provide support to CIHA and the overall revenue cycle, be a good steward of financial monies. Under administrative review, is responsible in initiating and coordinating the clerical, secretarial functions required and effective implementation of administrative policies and procedures of the Medicare and Medicare Advantage Program. The incumbent will serve as the CIHA Medicare representative, and will assist patients in obtaining necessary coverage.

Job Description

• Responsible for assisting in the oversight of Client Services; including guidance of eligibility with pharmacy, phone call interventions and the insurance continuation program with third party insurance and Medicare Part D.
• Must, assist with the development and implementation process of the programs policies and procedures. Develop checklists regarding the daily operations of Medicare and Medicare Part D services, and referrals to EBCI PHHS for Part D services.
• Provide training and staff development on the functions and importance of Medicare Part A, Part B and Part D; perform quality assurance activities regarding all aspects and requirements of the program’s eligibility for patient care.
• Coordinate with staff for the purpose of enhancing client access to comprehensive health care coverage.
• Responsible for reviewing system generated reports from the Electronic Health Record (EHR) on patients that have active Medicare coverage, or are becoming eligible for Medicare Coverage. Responsible for updating patient records in the Resource and Patient Management System (RPMS) for insurance information.
• Provide technical assistance to the patients enrolling in the program. Expect to have direct encounters.
• Review patient care plans for approval and document medical necessity for Medicare services and program requirements.
• It is imperative to stay up to date with changes in forms, regulations, processes and procedures.
• Develop and maintain a tracking process to ensure accuracy and integrity of enrollment records; review often for determination of coverage.
• Work with the Revenue Cycle Office staff for assistance and offer information and recommendations that will better the process.
• Must be able to adapt in stressful situations when dealing with disgruntled insurance representatives, patients, and providers.
• Performs other duties assigned, both in verbal or written communication by the Resource Manager or Director of Accessibility, Resources, and Member Services.

Education/Experience

• Completion of high school or equivalent is required.
• Four-year degree from an accredited college or university in a human services degree area and/or administration and three years’ experience in a benefit program, OR an Associate’s degree from an accredited college or university and five years’ experience as an income maintenance specialist in a benefit program, OR a high school diploma and seven years’ experience as an income maintenance specialist in a benefit program.
• Progressively responsible analytical, administrative, or clinical management experience is preferred.
• Work must have been performed in an operating health care facility or a higher echelon organization (ex. advisory or directional authority over health care facilities) with knowledge and skill in applying analytical and evaluative methods to program operation.
• Work must have involved a close working relationship with facility managers and clinical providers, analyzing and/or coordination of administrative, clinical, or other service activities.
• Will be expected with, approval from PHHS to become a SHIIP Volunteer and obtain certification and attend mandatory trainings required to keep active status.
• Administrative assistant and computer training experience are required to perform job duties. Position will require 1 ½ year becoming proficient in most phases of the job.

Job Knowledge

• Must be detailed oriented and have excellent organizational and time-management skills. Must be self-motivated and work with minimal supervision. Excellent verbal and written communication skills are essential.
• Great Skills in correlating generalized observations of data.
• Extensive knowledge of and ability to apply the Alternate Resource regulations: P.L. 94-437, Title IV of Indian Health Care Improvement Act , Indian Health Service Policy and Regulations on Alternate Resources, CFR 42-36.21 (A) and 23 (F), and P.L 99-272, Federal Medical Care Cost Recovery Act.
• Extensive knowledge of the, total, program operation, priorities and goals of the Alternate Resource Program, including eligibility requirements for the program and for third party insurance.
• Must be able to follow instructions, work on assignments independently, and be willing to address issues that help reach the CIHA mission.
• The ability to learn and the ability to be knowledgeable in the total program operation, hospital and departmental priorities, and goals of the Revenue Cycle Office and Resource Development Program.
• Require knowledge of the business use of computer hardware and software to ensure the effectiveness and quality of the processing and presentation of data. Require skill in the use of a wide variety of office equipment including: computer, typewriter, calculator, facsimile, copy machine, scanner, and other office equipment as required.
• Must possess a valid North Carolina driver’s license.

Competencies

• Communication: Establishes clear direction, distributes workload, lays out work in a well-planned and organized manner, and maintains a constructive two-way dialogue with others on tasks and results.
• Experience: Excellent verbal, written, presentation, and analytical communication skills, backed by strong experience with tools like Microsoft Office suite.
• Transparency: Embraces transparency in operations and reporting; understands and communicates the big picture and project details with accuracy and clarity.
• Problem Solving: Analytical, looks beyond the obvious and doesn't stop at the first answers, uses rigorous logic and methods to solve difficult problems with effective solutions, and probes all appropriate sources for potential answers.
• Driven: Self-motivated, goal oriented, quality driven, and capable of working independently with little supervision.
• Efficient: Uses time effectively, values time, and concentrates personal and team efforts on the most important or impactful priorities to enable project success.
• Detailed: Innate ability to organize, manage and prioritize with multiple disciplines by being highly detailed and thorough.

Complexity of Duties Duties are progressively complex, require planning and coordinating several activities at one time, and demand the use of problem-solving skills and analysis of circumstances to develop appropriate actions. Is subject to frequent interruptions, in person and by phone, which require varied response. Supervision Received Works under the direction of the Resource Manager. Has latitude for the exercise of initiatives, discretion, and independent judgment within the Cherokee Indian Hospital Authority. Responsibility for Accuracy Requires a high degree of accuracy. Work effects the accuracy and reliability of further processes, time schedules, staff time, and public relations. Most errors can be detected with proofing procedures. Errors may also have adverse effects on internal and outside relationships. Follows well define procedures and guidelines in job duties with minimal or no supervision. Must communicate and respond appropriately to various situations. Judgment and initiative are required to maintain accuracy, efficiency, and to prioritize work and meet deadlines. Contacts with Others Has frequent contact with Executive Directors, Medial Directors, Medical Staff, Program Directors and personnel, general public, Contractors, facility and maintenance vendors, Tribal Agents. CIHA and IHS regarding explanations, discussions, and procedures and obtaining approval. Contact involves dealing with superiors, employees and general public, contractors, facility and maintenance vendors, Federal, State, Tribal agents, CIHA and IHS regarding explanations, discussions, procedures and obtaining approval. Contact requires a high degree of tact, courtesy, and business etiquette to maintain positive working relationships. Confidential Data Works with and/or has access to highly confidential Division files, memos, contract proposals, personnel and payroll information of which would be considered confidential and should not be disclosed. Must adhere to all CIHA confidentiality policies and procedures, as well as the Privacy Act of 1974 and HIPAA. Mental/Visual/Physical Close concentration and attention to detail are required while performing most duties of the job. Is subject to frequent interruptions, both by phone and in person, which require varied responses with each contact. The duties of this job routinely require standing, walking, and sitting, kneeling, crouching, reaching, seeing, speaking, and hearing. May occasionally move more than 15 pounds. Environment Works in normal business office environment with occasional visits to program sites while performing job duties. May involve contacts with patients in both well and illness status. Customer Service Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.