Address: 1701 Golf Rd. Rolling Meadows, IL

Hours: 8am to 4:30pm

 Oncology/ Hematology

Major Responsibilities:

• Perform the specific tasks required for the efficient and effective operation of the Eligibility Department by providing creative analysis and judgment
  •     1)Responsible for the analysis and resolution of various complex and diverse eligibility issues in a timely manner, which would satisfy larger system objectives. Solves problems by using judgment based on knowledge of department policies.
  •     2)Investigate, analyze and develop creative solutions to specific member and provider problems related to eligibility, capitation, etc through active cross-functional participation.
  •     3)Responsible for research, verification and evaluation of eligibility issues stemming form Provider inquires, Provider offices, contracted Managed Care Organizations and various departments within Advocate Health Partners and Centers.
  •     4)Responsible for maintaining and updating of member eligibility information upon resolution of eligibility issues (i.e. member adds/terminations/reinstates/demographic updates/Primary care Physician update, etc)
  •     5)Research and resolves discrepancies in the PCP assignments between MCO eligibility files and the IDX system. Critical for accurate capitation payment.
  •     6)Analyze, request and process capitation adjustments and inquiries received from Providers, Provider offices, Managed Care Organizations, and from various departments (i.e. Finance/Recovery, Claims etc) within Advocate Health Partners and Centers.
  •     7)Investigate, process and resolve any retro enrollment issues and discrepancies. Ensure that capitation payment received from respective Managed Care Organization.
  •     8)Analyze, research and resolve copay issues, which directly affects Financials and claims payment.
  •     9)Receives and researches inquiries pertaining to eligibility issues for all AHPO and AHC sites, central departments, i.e. Referrals, Claims, Medical Services, Resolution Center, Provider Relations, Revenue Recovery, Provider, Provider Offices, etc.
  •     10)Analyze and reconcile duplicate accounts in the IDX system. All identified potential duplicate accounts must be reviewed for appointments, financial activity, claims referrals, medical record date, and merge as appropriate
• Accountability A continued…
  •     1)Researches insurance coverage on new, unverified members prior to their scheduled appointment and communicates outcome to the sites per established department guidelines.
  •     2)Assess the appropriateness for member requests to transfer sites adhering to the guidelines established by the Eligibility and Medical Services departments. Investigate and resolve transition of care issues.
  •     3)Facilitate the resolution of issues related to employer group linkage to benefit plan in IDX.
  •     4)Research, analyze, and reconcile the discrepancies between the Eligibility files received from the Managed Care Organizations against the information loaded in IDX. All enrollments must contain the correct group number, plan, and effective date, etc as reported by the MCOs. Reconciliation of the more complex eligibility issues will be assigned.
  •     5)Identify, evaluate, understand and process Coordination of Benefits information as it relates to Eligibility, Claims and Dept. Of Insurance guidelines, as well as determining its financial impact.
  •     6)Research claims that cannot be processed due to eligibility issues and maintains 24-48 hour turnaround time to insure claim payment compliance.
  •     7)Acts as a liaison between contracted Managed Care Organizations, Providers, Provider offices and internal customers (AHPO and AHC).
  •     8)Facilitates effective communication and follow up after resolution of issues
  •     9)Investigates and process month end reports including but not limited to: • Duplicate Contract Report • Pending Eligibility Verification Report • Duplicate Registration Report • MD Unassigned Report • Newborn Status Report • Over-Aged Dependent/Student Status Report • Transplant Status Report
• Interacting with complex and diverse eligibility issues with strong emphasis on formulating solutions and recommendations
  •     5)Perform other duties and tasks as assigned by Management.
  •     1)Provides input and assistance in the creation and maintenance of Eligibility Policy & Training Manual.
  •     2)Participate in task force meeting and process improvement teams and committees.
  •     3)Maintain open communication with Management and other departments; keep each abreast of problems and observations in the course of daily operations.
  •     4)Prioritizes day-to-day work assignments with minimal direction

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.