Under general supervision, performs financial counseling, screening and enrollment for medical coverage under the terms of various private and public health care and financial assistance programs including Medi-Cal and Medicare to maximize hospital reimbursement and facilitate patient care.
Positions in this classification are responsible for carrying out and explaining the provisions of various health care programs as well as the policies and procedures of the hospital as they pertain to financial counseling, screening and enrollment for the determination of eligibility for appropriate payor sources for medical treatment. Positions in this class communicate with patients, their relatives, hospital staff, and representatives of outside agencies and the public.
The 2908 Senior Hospital Eligibility Worker is distinguished from the 2903 Hospital Eligibility Worker in that the latter registers, admits and discharges patients and provides screening and enrollment services for categorical aid programs such as FamilyPACT, AIDS Drug Assistance Programs, and Every Woman Counts.
The 2908 Senior Hospital Eligibility Worker is distinguished from the 2905 Human Services Agency Senior Eligibility Worker in that class 2908 identifies and determines patient eligibility for medical coverage under the terms of various private health plans and public assistance programs, whereas class 2905 determines client eligibility for public assistance programs and certifies for reimbursement under the terms of various social services programs
Examples of Important and Essential Duties
According to Civil Service Commission Rule 109, the duties specified below are representative of the range of duties assigned to this job code/class and are not intended to be an inclusive list.
1. Explain programs, qualification standards, policy and procedure to patients; assist patients in completion of applications and forms when necessary; review and evaluate applications for completeness and accuracy; prepare patient budget to determine eligibility.
2. Conduct interviews with patients, their relatives and others in order to identify and determine patient eligibility for coverage of medical care under various Federal or State programs or under the provisions of private, fraternal, union or other health care plans; verify hospitalization insurance and arrange for billing of the appropriate agency or health care plan; continually reviews patient's case files to update vital statistics.
3. Obtain and provide medical and financial information with hospital staff, outside government agencies, and insurance providers; attend ward rounds with appropriate staff.
4. Determine patient eligibility for a third party payment source according to established policies and procedures including private health insurance plans, victims of crime, workers' compensation, and lawsuit settlements.
5. Initiate and obtain approval of extension of Medi-Cal coverage for emergency and elective admissions.
6. Prepare records related to patient eligibility information and health care payment received; update records; submit required reports.
7. Investigate statements and information received from applicant through the use of telephone or written verifications.
8. Review cases with supervisor in assessing the quality of payment source determination process and procedure.
9. Compose and prepare correspondence to patients, references, and State agencies; gather statistical data and prepare reports as required.
10. When assigned to a long term care facility, may regulate patient finances to maintain patient eligibility and entitlement to various benefits; may facilitate burial arrangements and final disposition of estate.
11. Refer non-payment cases to appropriate authority for recovery.
12. Answer questions and provide information to patient and the general public regarding assigned program area.
13. Assist in registering patients into the hospital; provide assistance to patients in completing applications; make referrals to Social Service agencies.
14. Perform related duties as required.
Knowledge, Skills and Abilities
Knowledge of: Procedures, methods and techniques of assessing and screening for eligibility for reimbursement from Medi-Cal, Medicare, and other public and private medical/financial assistance programs; methods and techniques of financial counseling; provisions of major public and private health care plans; principles and practices of caseload management; departmental programs, policies, procedures and terminology; medical terminology; principles and procedures of record keeping; interviewing and investigative skills and techniques; office procedures, methods and computer equipment; basic mathematics;
Ability to: Interview applicants to obtain appropriate information and to determine eligibility for reimbursement from third party payment source, often in different languages or dialects of English; accurately gather, record and evaluate data necessary for the determination of eligibility; evaluate data and provide recommendations on patient eligibility; interpret and apply Federal, State, local, hospital and Departmental policies, procedures, laws and regulations; work independently with minimal supervision; maintain accurate records and meet program deadlines; operate a computer terminal and standard office machines; make accurate mathematical computations; plan, organize and prioritize workload; type and enter data at a speed necessary for successful job performance; exercise sensitivity to the needs of the indigent sick; establish effective working relationships with representatives of public and private health care services; effectively communicate with and elicit information from patients and collaterals in difficult situations; communicate clearly and concisely, both orally and in writing; establish and maintain cooperative working relationships with those contacted in the course of work.
These minimum qualifications establish the education, training, experience, special skills and/or license(s) which are required for employment in the classification. Please note, additional qualifications (i.e., special conditions) may apply to a particular position and will be stated on the exam/job announcement.
Two (2) years of experience performing the duties of an Eligibility Worker in a hospital, medical clinic, Medi-Cal unit or a community-based health organization within the last five (5) years. The work experience must include determining eligibility for various Federal, State and county programs that reimburse for medical care.
License and Certification:
Must obtain Certified Enrollment Counselor Certification for Covered California and pass federal background check within 3 months of hire.
Disaster Service Workers
All City and County of San Francisco employees are designated Disaster Service Workers through state and local law (California Government Code Section 3100-3109). Employment with the City requires the affirmation of a loyalty oath to this effect. Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.