Medicaid Specialist

LINE OF AUTHORITY:

1. Business Office Department Head
2. Administrator

QUALIFICATIONS:

1. Degree
   • Prefer Master’s degree in Social Work from school or university accredited by the council on Social Work education or
   • Bachelor’s degree from accredited college or university
2. Experience in dealing with people in crises is preferable.
3. Knowledge of the case management process, needs of geriatric patients, health care settings, working knowledge of funding resources such as Medicare Part A, B, C and D, Medicaid, Managed Care and other private insurances.
4. Imagination and creative ability, skill in working cooperatively with other professionals, ability to organize and carry out responsibility efficiently and effectively.
5. Ability to communicate effectively and appropriately both verbally and in writing in a wide variety of circumstances.
6. Commitment to the mission and goals of the center.
7. Ability to exercise independent judgment where procedures cannot be standardized.
8. Dedicated totally to the success of the center and The Better Way culture.

PHYSICAL DEMANDS:

1. Able to lift 20-40 lbs. on occasional basis.
2. Able to bend, stoop, squat and twist numerous times daily.
3. Able to see and hear adequately in order to respond to auditory and visual requests from patients.
4. Able to speak in a clear concise voice in order to communicate with patients who may be hearing impaired.
5. Able to carry out fine motor skills and manual dexterity.
6. Able to manage own stress effectively.

Working Conditions:

1. Well lighted, well ventilated office space.
2. Interacts with general public under all conditions. Much of the work involves difficult circumstances, patient and families in emotional distress, severe illness, dying, death and grief, confusion, combativeness, ill-temper, etc..
3. Constant pressure to respond maturely and effectively with patients, families, other staff and other professionals.
4. Must appropriately represent center in dress and demeanor per the partner handbook and any written regional policy.

DUTIES:

(Note: Specific duties are assigned at the discretion of the Business Office Department Head and may be adjusted to meet the needs/expertise of personnel available.)

General Description:

1. Gather current information available about funding resources.
2. Work with individual patients and families toward understanding there funding resources
3. Inform individual patients and families of the need for applying and becoming eligible for Medicaid benefits.
4. Assist individual patients and families with their application for Medicaid benefits including but not limited to gathering supporting documentation.
5. Assist individual patients and families with their renewal applications for Medicaid benefits including but not limited to gathering supporting documentation.
6. Serve in an advocacy role for patients and their families in expressing, defining and resolving grievances.
7. Participate in in-service training programs.
8. Evaluate the quality of the Business Office and of Social Services as part of the center’s overall quality improvement program.
9. Develop and maintain contacts with appropriate community agencies.
10. Handle some marketing activities/functions assigned by the Business Office Department Head.

Duty Areas

1. Funding information:
   **Provide family and patient with accurate, up to date information regarding funding resources such as Medicare Part A, B, C and D, Medicaid, and Private insurances.
2. Inquiry Management:
   • Maintain professional working relationship with government agencies including the Tennessee Department of Health, Hamilton County DHS office and Social Security Administration to share and obtain information concerning a patient’s application for Medicaid benefits and any renewals.
3. Financial/Medical Records:
   **Keep current a report summarizing the financial and discharge status of all patient’s who may possibly need Medicaid benefits.
   • Create and maintain files on all patients who may need or who have Medicaid benefits,
   • Document, clearly and legibly.
   • Document reports of progress at required intervals.
4. Ombudsman:
   • Maintain relationship with patient and family in order to facilitate early identification of potential problems.
   • Maintain close working relationship with all other departments in appropriately resolving grievances.
   • Identify and report trends or patterns of complaints to the Business Office Department Head.
   • Manage difficult or emotional customer situations.
5. Case Management with patients and families:
   • Respond to immediate need of any patient or family referred by floor staff, DON, therapists, administrator, or physician.
   • Encourage maximum participation of family in meeting needs of patients.
   • Respond promptly to customer needs.
   • Proactively work to meet and/or exceed customer expectations.
   • Build a relationship of trust and respect with customers.
   • Develop knowledge of criteria utilized by Medicaid and other third party payors for continued stay authorization in order to educate patient and families.
6. Transition/Discharge Planning:
   • Obtain information from family and patient on admission regarding expectations and resources available for discharge planning.
   • Collaborate with other care plan team members to confirm and stay current on a patient’s discharge plans.
   • Coordinate in-house planning and assist patient and family in obtaining services needed to assure continuity of care.
   • Participate in Utilization Review to advise committee on discharge planning.
7. In-Service Education:
   • Participate in continuing education programs available, with consent of Business Office Department Head.
   • Participate in in-service education of staff in areas of expertise, especially emotional needs of elderly, patient’s rights, confidentiality and the Abuse Policy.
8. Quality Improvement:
   • Participate in quality improvement program of center.
   • Understand the QI process.
   • Participate in survey processes conducted by state regulatory agencies.
9. Other duties which may be assigned by Business Office Department Head.

RESPONSIBILITIES:

1. The Medicaid Specialist is responsible for the quality of Business Office and Social Services rendered by the center.
2. Report to the Business Office Department Head the current status of the business office and present needs as perceived by the Medicaid Specialist.
3. Understand and abide by established policies of health care center and interpret them to concerned parties.
4. Participate in consultation with the Business Office Department Head, especially pointing out problems and trends that may require company policy attention.
5. Maintain confidentiality of professional information.
6. Abide by the Policies and Procedures in the Business Office Manual and the Social Services Manual.
7. Account for use of time, report sickness, and plan vacation time with the Business Office Department Head.
8. Assuring Resident Safety