Eligibility & Enrollment Specialist

The Woodlands, TX 77380

Posted: 12/04/2018 Category: Customer Service Job Number: 23217
Eligibility and Enrollment Specialist Description:
  • The Oncology Eligibility Coordinator conducts and assists in all aspects of both determining eligibility and enrolling patients into programs by executing the following duties: Reviewing and understanding the contractual requirements that determine eligibility for this program, navigating through medical records and practice manangement systems in addition to internal Innovent IT systems, and utilizing understanding of Oncology terminology and critical thinking to gather data to summarize the treatment plan for each patient to complete enrollment.
  • Additional job functions include: Providing completed work each day to the payer, answering questions from the payer about enrolled patients and marking outcomes of eligibility into the Innovent IT system.
  • Understanding the basic rules for Billing the episodes in order to communicate well with the Practice billoing department. Maintaining various reports / spreadsheets, supports and adheres to the Client' s compliance program, to include the Code of Ethics and Business Standards as well as all HIPAA protocols and client contractual obligations.
Key Responsibilities:

Assists in all aspects of determining patient eligibility for client programs.
  • Follows specific contract requirements-must understand details of contracts.
  • Navigate through multiple IT systems.
  • Review of Electronic Medical Records for active treatments and plan of care.
  • Understanding of Oncology Chemotherapy treatments ( IV/Oral /Hormonal)
  • Verification of insurance benefits.
  • Responsible for understanding basic billing rules for episodes.
  • Understanding of different Payment Conditions.
Communication with Provider and Payers
  • Answer questions from Payer about eligibility and Payment conditions.
  • Discuss with Provider basic rules for billing of episodes.
  • Work with Analytics team regarding gathered data.
Assist in all aspects of enrolling eligible patients into client' s Programs:
  • Document in client' s IT systems.
  • Populate all required information into the Payer Spreadsheets.
  • Outreach to provider to obtain missing clinical data.
  • Populate all data on Master Spreadsheet.
  •   Assist with reviewing patients as needed for payer and provider audits of enrolled patients. 
Critical Skills: (must have)
  • Knowledge of Medical Terminology.
  • Advanced Microsoft Word, Outlook.
  • Analytical Thinker and Problem Solver -Extremely important.
  • Self Motivator - works efficiently without daily direction
  • Highly Organized.
  • Multitasker who can prioritize job duties.
  • Excellent Telephone Skills.
Additional Knowledge/Skills: (preferred)
Oncology terminology.
Understanding of Adjuvant and Metastatic patients.
Understanding of IV Chemotherapy treatments /Hormonal only treatments / Palliative Care.
Understanding of reading a Pathology /CT /PET etc reports and determining the outcome.

Working Conditions:
  • Environment (Office, warehouse, etc.) - The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Work is performed in an office, clinical or classroom environment and requires significant interaction with corporate and network staff.

Physical Requirements (Lifting, standing, etc.) 
  • The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions, while performing the duties of this job, the employee is regularly required to sit or stand and talk or hear.
  • The employee frequently is required to use hand to finger, handle, or feel and occasionally required to reach with hands and arms.
  • he employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 10 pounds.
  • Specific vision abilities required by this job include close vision and ability to adjust focus.
For more information on this position, please contact our office at 877-782-3334.


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