Medicaid Eligibility Analyst

North Carolina, United States
15 Oct 2018
End of advertisement period
15 Dec 2018
Contract Type
Full Time


Job Description

General Description of the Job Class 

Coordinate and facilitate the Medicaid/Market Place Insurance application process across multidisciplinary entities to obtain eligibility for patients entitled to Medicaid/Insurance for the purpose of attaining reimbursement for services provided by Duke University Health System.

Duties and Responsibilities of this Level 

  • Conduct thorough, in-depth interviews and evaluate patient's case for potential eligibility for Medical Assistance Programs and any applicable Purchase of Medical Care programs.
  • Conduct Screening for ACA eligibility and assist with applying for a coverage plan through the Market Place during the open or post enrollment period.
  • Analysis of patient's assets, income, clinical history, and dependent responsibilities, must be conducted in a precise manner based on knowledge and interpretation of the federal regulations and Social Security Administration guidelines.
  • Assess patient's continuing care needs and determine correct program and certification period to minimize patient deductible and maximize entity reimbursement.
  • Communicate and advise patients on complex financial concepts and procedures of applying for Medicaid/Insurance coverage.
  • In some cases, may act as the authorized patient#s representative for the purpose of initiating an application for benefits and for conducting any and all activities associated with determination of eligibility of benefits, including the initiation and conduct of administrative and /or judicial appeals.
  • There is legal liability involved for the Medicaid Eligibility Analyst, as they are responsible to the county/state for the accuracy of information and actions taken on behalf of the patient.
  • The Medicaid Eligibility Analyst has the ability to act for the individual and exercise the individual's rights.
  • Perform research daily to resolve eligibility issues.
  • Coordinate and facilitate the completion of the Medicaid application and assist with the online Market Place Insurance process.
  • Gather and provide necessary verifications to establish eligibility via direct contact with patient and/or patient's family, employer, financial institution, vital statistics and other collaterals to the County Department of Social Services Income Maintenance Caseworker in the county of patient residency.
  • Follow-up with patient and the Department of Social Services to ensure all pertinent information has been provided relevant to the Medicaid application.
  • This may require travel to county of patient residency for the purpose of transporting the patient to the Department of Social services for follow-up visits, obtaining additional records, and verifying or correcting information on behalf of the patient.
  • Anticipate and troubleshoot logistic and compliance barriers.
  • Review medical evidence, requests and compiles evidence from sources, including employers, physicians, hospitals, and health agencies, by contacting parties via telephone or correspondence in order to make an eligibility/appeal determination.
  • Interprets and communicates eligibility requirements, policies, and procedures to internal and external customers and writes and/or completes appeal summary reports, physician questionnaires of medical necessity and other correspondences pertaining to eligibility findings.
  • Determine the need for consultative examinations by reviewing case files and supporting medical documentation.
  • Confer with medical consultants for interpretation and analysis of technical medical data by phone or correspondence.
  • Evaluate case files to determine issues and sufficiency of evidence or documentation, analyzing Social Security Administration rules, Division of Medical Assistance guidelines and relevant regulations for applicability. Initiate fact finding, research in support or denial of case merit.
  • Based on findings, evaluate if challenge is appropriate and facilitate the request for a hearing from the responsible local agency or State Office of Hearings and Appeals if warranted.
  • Prepare hearing briefs; assemble documentary evidence and exhibits to represent the patient at local agency, State and Chief Hearing Officer Hearings for the purpose of reversing a negative decision with or without the patient's assistance.
  • Interview, evaluate and prepare potential witnesses for substantive evidence in support of the decision reversal.
  • Present patient case, examine and cross examine witnesses, and enter evidence into the case file at adjudication hearings to establish patient's eligibility for Medicaid.
  • Responsible for entering pertinent information into the hospital system and closely monitoring authorization dates and deductible amounts applied to patient accounts.
  • Reconcile account financial status coding monthly to ensure accounts are represented accurately.
  • Serve as an educational resource on Medicaid/Market Place Insurance issues for patients, Social Workers, Physicians, Clinic and Admissions personnel.
  • Review and monitor revisions in policy/regulations for all Medicaid programs on a regular basis to determine the effect of these revisions on pending applications.
  • Perform other related duties incidental to the work described herein.

Knowledge, Skills, and Abilities: 

  • Four years of related experience is required.
  • Preferred qualifications include previous experience determining Medicaid eligibility in a hospital or DSS setting.
  • Ability to work independently and in a strong team environment.
  • Ability to project a positive attitude and high degree of self-confidence.
  • Ability to effectively manage time.
  • Strong analytical, research and problem solving skills
  • Strong verbal and written communication skills
  • Computer Skills ( Word, excel, power point, Epic)
  • Knowledge of NC FAST eligibility system used by county departments of social services..
  • Knowledge and use of NC Tracks for insurance eligibility verification.
  • This position requires the use of Modified Adjusted Gross Income (MAGI) methodology
  • This position is required to help meet the general requirements imposed by Section 501(r).
  • Valid Driver's license and clean driving record 

Distinguishing Characteristics of this Level 

  • The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position.
  • Employees may be directed to perform job-related tasks other than those specifically presented in this description.

Requisition Number 401504114
Location Durham
Duke Entity PRMO
Job Family Level D2
Exempt/Non-Exempt Exempt
Full Time / Part Time FULL TIME
Regular / Temporary Regular
Shift First/Day

Minimum Qualifications

Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex,sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation,creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feelsecure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions:Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.


Bachelor's degree in business, healthcare administration, accounting,finance or a related field is required.


Four years of related experience is required.

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