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JOB PURPOSE: The Eligibility Specialist is responsible for performing administrative duties and processing which include the determination of eligibility for services and application assistor in support of El Rio Health Center services and its varied operations. The incumbent in this position will possess and demonstrate an advanced and comprehensive understanding of community, government, and private social services/agencies and programs; serves as an informational resource to clients and staff members. This includes eligibility requirements and procedures to effectively support the recruitment, registration, enrollment, and retention of consumers to the ACA Marketplace, AHCCCS, or discount programs; as well as referrals to social services or agencies. 

An Eligibility Specialist works with intermittent supervision and review, and any work problems involving departures from standard policies, interpretations, or procedures are reviewed with the supervisor, or applicable agency representative for resolution.

Essential Job Functions:

• Performs all assigned tasks, responsibilities, and assignments supporting departmental operations within established periods; meeting established rates of performance for the quality and quantity of work for the position; and demonstrating the highest levels of professionalism, quality, efficiency, and accuracy in the employee’s job performance that exhibits the highest standards of excellence.
• Understands and complies with all organizational Code of Conduct standards, Policies and Procedures, and Service Excellence requirements with all consumers, patients, visitors, employees, and internal/external clients or representatives.
• Maintains at all times employee and/or patient confidentiality by controlling the environment and information being disclosed to authorized individuals ensuring compliance with all HIPAA and corporate compliance standards, as well as accepted human resources confidentiality standards.

• Gains and maintains a comprehensive and advanced knowledge, skills, and expertise on governmental and private healthcare programs, such as:
• Affordable Care Act, Healthy Arizona Plus, Sliding Fee Scale, etc.
• Performs ongoing investigative research in order to provide informational summaries and training on governmental and private healthcare programs.
• Serves as trainer and mentor to new and existing staff members on regulatory changes.
• Facilitates annual refresher or recertification training on the Affordable Care Act and other governmental or private healthcare programs.
• Participates in the review and development process of department operational policies and procedures.
• Provides recommendations on operational functions and process improvement or enhancement.
• Fulfills and performs all of the functions, duties, and responsibilities of an Eligibility Assistant.
• Provides timely and accurate scheduled or ad hoc reporting to internal/external departments or representatives, such as:
• Performs client eligibility status look up
• Provides system generated reports
• Performs data collection on outreach and operational activity
• Gains and maintains the knowledge, understanding, and skills to complete assigned administrative and clerical duties, tasks, and assignments working with program operating systems, programs, and/or business software, such as: 
• Gains and maintains all training requirements and certifications necessary for eligibility and enrollment processing; and to serve as a Certified Application Counselor for the Affordable Care Act;
• Supports and assists consumers with public access and enrollment to HEAPlus and ACA Marketplace applications utilizing web based systems and software.
• Generates and distributes reports, summary information, and correspondence for the program for internal/external clients or representatives; as well as assisting with data entry of information and content into program systems, software, or spreadsheets for effective operational use and reporting.
• Supports and assists consumers by providing explanations, enrollment assistance, and information on eligibility options and requirements for programs such as: Medicaid (AHCCCS), ACA Marketplace.
• Demonstrates an exceptional level of customer service; answering and responding to all incoming calls, emails, and inquiries in a timely and effective manner; responding to requests for support providing information and solutions in response to inquiries; resolving technical inquiries or complaints.
• Maintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures including but not limited to work areas, workstations, examination rooms, hand washing, infection prevention and control etc. for this position.
• Demonstrates an understanding of and proficiency with the application of all compliance and reporting requirements respective to Joint Commission Certification (JCC) standards.
• Communicates effectively through written, verbal, and interpersonal skills as applied when interacting with employees, internal/external clients or representatives, patients, or visitors, successfully conveying and exchanging information in a positive manner.
• As a team player demonstrates self-initiative by being aware of the work environment in order to assist co-workers and others while maintaining and enhancing a respectful and positive attitude in the work environment.  Serving at all times as a positive and effective employee.
• Participates in a learning environment by being willing to teach other employees, providing new skills and knowledge that will enhance and improve the quality of service provided to consumers, as well as all internal/external clients or representatives.
• Serve as a contact point and liaison to internal departments and staff for problem-solving and in-service training related to eligibility services.
• Facilitates internal and external informational presentations to community groups or individuals on Affordable Care Act, AHCCCS, and other eligibility services.
• Performs public speaking on eligibility services to large and small groups in informal or formal settings;
• Creates presentations and materials that will meet the Center for Medicare/Medicaid Systems (CMS) guidelines and approval.
• Supports El Rio Health by participating in community events that promote good health and which contribute to a broader awareness and understanding of the governmental and private healthcare programs or services available to the community.
• Completes administrative processing of operational activity into program systems or spreadsheets to support effective and timely tracking, reporting, and invoicing of application completion and production.
• Gains and maintains proficient skill with all organizational or agency operating systems and programs by adapting to changing requirements and successfully learning and demonstrating new skills in response to system and program improvements or upgrades.

Minimum Education and Experience:

• A High School Diploma or General Education Diploma (G.E.D.)
• Three (3) years’ experience working as an Eligibility Assistant, Outreach Worker, or Certified Application Counselor for the Affordable Care Act.

If applicable, equivalent combination of education and experience may be considered, and must be directly related to the functions and responsibilities of the job.

Required Licenses, Certifications, and Registrations:

• Upon employment: gains and maintains certification and licensing as a Certified Application Counselor for the Affordable Care Act.
• Level I fingerprint clearance card: current valid and in good standing or have applied for it within seven working days after beginning employment
• Employees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday.  If an employee is driving during work hours, the employee is required to possess a valid driver’s license and must comply with Arizona vehicle insurance requirements.

Preferred Education, Experience, Skills, Abilities:

• Bilingual (English/Spanish) with the ability to speak, read and write in both languages.

Reasonable accommodations may be made to enable individuals with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for sincerely held religious beliefs, observances, and practices to perform the essential functions of the job.

 El Rio Health does not discriminate based on race, color, religion, sex (including pregnancy, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, or other non-merit-based factors. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.

El Rio Health requires all AZ employees to have a Level One Fingerprint Clearance card. A.R.S. 36.425.03. New hires and transfers must submit their fingerprint clearance card or fingerprint receipt before their hire date or transfer date. Level One (1) Non-IVP Fingerprint Clearance card must be received within 30 days after the new employee hire date or transfer date.

 All employees are strongly recommended to obtain and maintain vaccination status (i.e., as recommended by CDC and/or other public health agencies) to include an Influenza vaccination. Subject to exemptions and accommodations when required by law. (Policy: Adm-016 & Adm-045).

 All employees are required to undergo drug testing prior to employment and will be subject to post-accident, reasonable suspicion, return to duty and follow up drug and alcohol testing in compliance with Federal and State regulations for alcohol and controlled substance testing. Employees in positions holding responsibility for the safety and welfare of others will also be classified as safety sensitive.

 El Rio Health is a non-profit 501(c)(3) Federally Qualified Health Center (FQHC) and abides by all applicable federal Drug-Free Workplace standards. El Rio Health is an equal opportunity employer.