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Posted: 01-Jul-25
Location: Durham, North Carolina
Internal Number: 259039
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke Health's Patient Revenue Management Organization
Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions.
MEDICAID ELIGIBILITY ANALYST Duke University Health System - Patient Revenue Management Office (PRMO) seeks to hire a Medicaid Eligibility Analyst who will embrace our mission of Advancing Health Together.
This is a hybrid remote position working between 1-4 days a week remotely depending on the needs of the department
Work Hours:
Monday - Friday 8:00am - 5:00pm
Bilingual strongly preferred
General Description of the Job Class
Coordinate and facilitate the Medicaid application process across multidisciplinary entities to obtain Medicaid eligibility for patients entitled to Medicaid for the purpose of attaining reimbursement for services provided by Duke University Health System.
Duties and Responsibilities of this Level
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.
Performance Standards
The Medicaid Eligibility Analyst is required to meet the following performance standards on a monthly basis:
- Average screening turnaround to resolution within 14 days of receiving referral
- Follows-up on Medicaid applications at a minimum of every 15 days, and resolves accounts on average within 90 days of application submission
- Achieves 80% or greater for Medicaid application approval percentage
- Achieves 90% or greater on monthly attorney review/auditing
Required Qualifications at this Level
Education:
Bachelor's degree in business, healthcare administration, accounting, finance or a related field is required.
Experience:
Four years of related experience is required.
Knowledge, Skills, and Abilities:
Bilingual strongly preferred
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.
Distinguishing Characteristics of this Level:
Position responsible for high production generated accurately in accordance with established business processes or regulation. Requires working knowledge of compliance principles. Job allows the opportunity to work independently.
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends onthe robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.