JOB DESCRIPTION

Determine applicant eligibility for health insurance, process data necessary for admission of new patients into health services, ensure proper coding for insurance billing, and handle inquiries from prospective applicants and patients.

SKILLS AND APTITUDES NEEDED

Good communication and customer service skills Familiar with computers, good typing skills Basic knowledge of anatomy Analytical and organizational abilities

This occupation is evolving from the insurance policy processing clerk. Medical Eligibility Specialists may be employed in hospitals, private medical cost management companies, insurance companies, or county and state welfare offices. Specialists must maintain a working knowledge of CPT and ICD- 9 coding principles, governmental regulations, protocols and third party requirements regarding billing and billing documentation. They must assure that all services documented in a patient’s chart are coded appropriately.

Specialists in a medical cost management company must be familiar with medical codes and terminology to determine eligibility for insurance benefits and reduce non-payments.

Specialists in an insurance company process applications for changes to, reinstatement of, and cancellation of insurance policies. They review applications to insure that all questions have been answered, compile data on policy changes, determine automatic reinstatement according to company policies, and verify accuracy of company records.

Specialists in a welfare office obtain, verify, and calculate income and resources to determine client financial eligibility for services such as Medicaid programs.