Enrollment & Eligibility Specialist I

Department: Finance 

Position Type: Full-Time

FLSA: Non-exempt 

Job Summary: 

Join us and be a part of Trillium Health, a mission-driven organization committed to expanding access to high-quality, compassionate care for everyone we serve.

The Enrollment & Eligibility Specialist I is responsible for the patient insurance verification process to ensure appropriate payment from insurers and provider assistance to reduce out-of-pocket expenses related to services provided in a clinical setting, including PrEP/Sexual Health services. This role assesses and enrolls patients in assistance programs for which they qualify, interprets and applies sliding fee scales, ensures accurate documentation within the electronic medical record, advises on policies and procedures related to uninsured patients, and supports collaboration across departments.

Duties/Responsibilities: 

Patient Insurance Verification Process

• Perform insurance verification checks at least seven (7) days prior to patient appointments to maintain compliance with organizational financial clearance guidelines.
• Ensure primary and secondary insurance designations are accurately represented within the electronic health record.
• Contact patients when insurance verification results in an invalid status and establish a strategy for addressing coverage gaps, including referrals to services and coordinating appointment rescheduling as needed.
• Ensure patient demographic information is maintained and updated.
• Assess patient eligibility for Medicaid, Medicare, and private insurance available through the New York State Marketplace and assist patients with applications.
• Assist patients in applying for insurance assistance during ACA Open Enrollment.
• Complete the "Know Your Coverage" scorecard and educate patients regarding coverage information.

Sliding Fee Scale

• Interpret and apply both the FQHC Sliding Fee Scale and the Ryan White Sliding Fee Scale.
• Ensure all related documentation is accurately and consistently captured within the electronic medical record.
• Educate patients and prospective patients regarding sliding fee scale eligibility and application.

Policies and Procedures

• Follow all established policies and processes related to uninsured patients.
• Collaborate with the Manager, Enrollment & Eligibility regarding policy implementation and compliance.

Cross-Departmental Support & Collaboration

• Communicate directly with patients who submit billing and reimbursement questions through the patient portal.
• Collaborate with Front Office teams to coordinate enrollment and eligibility follow-up activities as needed.

Miscellaneous

• Requires the ability and commitment to respect and support patients, other employees, and visitors with various lived experiences.
• Requires individual demonstration of commitment to the mission, vision, One Trillium values, behaviors, and modeling them in the organization.
• Responsible for maintaining confidentiality of all patient, client, employee, protected, and proprietary information.
• Employees are accountable for meeting departmental performance standards and must participate as requested in compliance audits and quality improvement plans.
• Required to participate in continuous improvement of job responsibilities and organizational or work processes to advance the organization or department.
• Other duties as assigned.

Required Skills/Abilities: 

• Knowledge of sliding fee scales.
• Knowledge of insurance processes, including prior authorizations.
• Ability to effectively manage multiple tasks throughout the workday.
• Proficiency in Microsoft Office and computerized systems for data entry and reporting.
• Proficiency with electronic medical record systems.
• Excellent organizational, communication, and interpersonal skills, both written and verbal.
• Strong listening skills and ability to give and receive constructive feedback.
• Ability to function both autonomously and collaboratively as part of a multidisciplinary team.

Education and Experience: 

• High school diploma or equivalent required. 
• Minimum of one (1) year of experience working in insurance enrollment, eligibility verification, or related position required.
• Preferred New York State Insurance Assister certification with at least one (1) year of experience as a certified Insurance Assister.

Physical Requirements

While performing the duties of this job the employee is required to stand, sit, walk, use hands to finger, handle, or feel; reach with hands and arms, talk and hear.  Occasionally the employee must stoop, bend and lift or move up to 25 lbs.  Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.  

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.