Eligibility Manager

Position Summary:
The Eligibility Manager leads the Eligibility Department and Community Resource Coordinator, overseeing daily operations, staff performance, workflows, complex determinations, and compliance. As the subject matter expert for eligibility, financial assistance, insurance coverage, public benefits, and patient resources, the manager partners with clinical, registration, revenue cycle, billing, and leadership teams to improve access, reduce errors and delays, and connect patients with appropriate resources.

The Director will support ECH's Access, Stewardship, and Quality (ASQ) priorities by improving access to care through efficient revenue cycle processes that reduce barriers to services, promoting stewardship through effective revenue cycle operations and financial performance, and enhancing quality through accurate, compliant revenue cycle practices and positive patient financial experience.

Essential Functions:
Department Leadership and Operations

• Plans, organizes, assigns, directs, and reviews the work of the Eligibility Department and Community Resource Coordinator to ensure efficient and consistent daily operations.
• Provides effective leadership, supervision, coaching, and performance management to eligibility and community resource staff.
• Establishes, maintains, and continuously improves department workflows, procedures, and standards to promote timely, accurate, and consistent eligibility services.
• Monitors department workload, productivity, turnaround times, accuracy, and other performance indicators and takes appropriate action when improvement is needed.
• Ensures staff has the knowledge, resources, and support necessary to determine and document patient eligibility and financial assistance appropriately.
• Provides guidance and support to staff regarding complex or unusual eligibility situations and assists with resolving escalated patient concerns.

Eligibility, Financial Assistance, and Patient Access

• Oversees the accurate and timely determination of patient eligibility for applicable healthcare programs, financial assistance, discounts, and other available resources.
• Maintains working knowledge of programs and resources available to uninsured, underinsured, and low-income patients and ensures staff appropriately screen and educate patients regarding potential eligibility.
• Ensures eligibility and financial assistance processes are applied consistently and in accordance with organizational policies and applicable program requirements.
• Supports accurate application of financial assistance and sliding fee policies, including appropriate documentation, verification, and determination of eligibility.
• Identifies barriers that may prevent patients from accessing care and works with staff and other departments to identify appropriate solutions and resources.
• Ensures patients receive clear, understandable information about available services, financial assistance options, eligibility requirements, consents, and their rights and responsibilities.
• Provides guidance when patients are determined to be ineligible for a service or program and works collaboratively with leadership and appropriate departments to determine the best course of action.
• Ensures patients are connected to appropriate community resources, public assistance programs, insurance coverage, or other support services when available.

Compliance, Accuracy, and Quality

• Ensures eligibility documentation is complete, accurate, timely, and maintained in accordance with organizational policies and applicable regulatory and program requirements.
• Conducts or oversees case reviews and quality audits to identify trends, errors, training needs, and opportunities for process improvement.
• Develops and implements corrective actions and process improvements when eligibility errors, workflow issues, or compliance concerns are identified.
• Maintains current knowledge of changes to eligibility programs, financial assistance requirements, payer requirements, and other regulations or policies that affect patient eligibility and access to care.
• Collaborates with leadership and other departments to ensure eligibility practices support accurate patient accounts, appropriate financial assistance determinations, and overall organizational compliance.
• Participates in quality assurance and performance improvement activities and uses data and departmental trends to identify opportunities for improvement.

Patient and Internal Customer Service

• Communicates professionally and respectfully with patients, families, staff, providers, leadership, community agencies, and other stakeholders regarding eligibility and financial assistance matters.
• Responds appropriately to patient questions, concerns, and complaints in person, by telephone, email, or other approved methods of communication.
• Handles sensitive financial and personal information with discretion and maintains patient confidentiality at all times.
• Uses clear, culturally responsive, and patient-centered communication methods to help patients understand their eligibility, financial responsibilities, and available resources.
• Demonstrates empathy and respect when working with patients who may experience financial hardship, limited health literacy, language barriers, or other barriers to accessing healthcare.
• Promotes a positive patient experience by ensuring eligibility concerns are addressed promptly, accurately, and respectfully.

Collaboration and Teamwork

• Collaborates effectively with Registration, Revenue Cycle, Clinical Operations, Behavioral Health, Dental, Primary Care, and other departments to support coordinated patient access and accurate eligibility processes.
• Works with community organizations and external agencies to identify and connect patients with appropriate resources.
• Provides education and support to other departments regarding eligibility processes, financial assistance, and available patient resources as appropriate.
• Demonstrates strong interpersonal, communication, and problem-solving skills to promote effective collaboration and patient satisfaction.

Additional Requirements:

• Complete all required training as designated by Human Resources and the position supervisor.
• Adhere to all organizational policies and those outlined in the Elevated Community Health Employee Handbook.
• Comply with all applicable Elevated Community Health vaccine mandates.
• Ability to travel and work at other Elevated Community Health locations as determined by the supervisor.
• Embrace the Elevated Community Health Mission and Vision and work within the organization's Guiding Principles and expectations established by the position supervisor.
• Participate in quality assurance and performance improvement activities as applicable.
• Maintain confidentiality and comply with all applicable privacy and information security requirements.

Qualifications:
To perform this job successfully, an individual must be able to engage in each essential duty satisfactorily. The requirements below represent the required knowledge, skills, and/or abilities. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Education/Experience:

Must-haves to be successful:

• Associate or bachelor's degree in healthcare or business administration, social services, or a related field, or equivalent work experience.
• 3 years' experience in eligibility, financial assistance, healthcare access, patient financial services, public assistance programs, community resource navigation, or a related healthcare setting.
• 2 years of supervisory experience
• Knowledge of CO Medicaid, Medicare, and other public health benefits programs
• Knowledge of the relevant chapters of the HRSA Health Center Program Compliance Manual, including Sliding Fee Program and Billing Compliance (bphc.hrsa.gov/compliance)
• Strong written and verbal communication skills.
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.
• Ability to maintain accurate, timely, and concise documentation.
• Ability to communicate effectively and respectfully with patients, coworkers, providers, leadership, community agencies, and other stakeholders.
• Ability to work effectively with individuals from diverse backgrounds and with varying levels of health literacy.

Nice to have:

• Bilingual Spanish/English
• Previous experience working for a Federally Qualified Health Center (FQHC).
• Experience with electronic Medical and Dental Office Practice Management systems
• Experience with quality assurance, compliance monitoring, process improvement, or departmental performance reporting.

Principal Working Relationships:

• Revenue Cycle team
• Front desk employees
• Service Line Directors
• FQHC support organizations such as CCHN and Carina
• Medicaid and Medicare organizations such as HCPF, RAEs, and MACs

Work Environment:
The work environment is a healthcare setting and can be fast-paced and involves communication with patients and clinical personnel. The position requires the ability to work autonomously and stay on task. The noise level in the work environment is usually moderate.

Physical Demands:
The physical demands described here are representative of those required by an employee to perform the essential functions of this job successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.