<p>Cooperative Health is a Federally Qualified Health Center (FQHC) providing ambulatory primary care to patients across 19 primary care offices located in Richland, Lexington, Fairfield, and Newberry counties. Our practices are recognized as Patient-Centered Medical Homes (PCMH), a designation that reflects a commitment to high-quality, team-based care in Pediatrics, Internal Medicine, and Family Practice. The PCMH model is an advanced care delivery approach that emphasizes collaboration among healthcare providers and actively engages patients-and, when applicable, their families or caregivers-as integral members of the care team. This model promotes continuous quality improvement, enhanced patient access, coordinated care, and the delivery of comprehensive, holistic services through a team-based structure.</p> <p>JOB SUMMARY</p> <p>Cooperative Health is seeking an innovative, enthusiastic individual with strong customer service skills, experience in case management, and proficiency in communication and Microsoft applications (e.g., Excel spreadsheets). Under the general supervision of the Ryan White Program Manager, this position will focus on actively engaging, enrolling, and retaining clients in health coverage while working as part of an inter-disciplinary team. The role involves communicating with clients about how to stay enrolled and utilize their health coverage effectively, as well as building departmental health insurance literacy to improve clients' ability to navigate the healthcare system and achieve better health outcomes.</p> <p>This position is also responsible for streamlining workflows to prepare clients for open enrollment and to help maintain coverage for current enrollees within the Marketplace. A strong understanding of Ryan White HIV/AIDS Program services is essential, particularly the Health Insurance Premium and Cost Sharing Assistance Program, which provides financial assistance to eligible clients living with HIV to help maintain continuity of insurance and access to medical and pharmacy benefits.</p> <p>In addition, this position serves as the Referral Specialist. This role supports the clinical site by managing all phone contact related to referral appointments. The specialist schedules specialty referrals, including diagnostic and imaging appointments, with both internal and external specialty providers. Responsibilities include following up with providers regarding appointment availability, pricing, and any special accommodations needed for patients. The specialist also documents all relevant information accurately in the electronic health record (EHR) system and communicates appointment details to patients.</p> <p>ESSENTIAL FUNCTIONS</p> <p>Affordable Care Act (ACA)</p> <ul> <li>Conduct onsite (clinic) enrollment activities with established partnerships as assigned </li><li>Understand Medicaid enrollment is continuous throughout the year </li><li>Collaborate with 3rd party entity to facilitate patient health insurance enrollments). Coordinate with 3rd party responsibilities which include: </li></ul> <p>o Follow all enrollments in real-time;</p> <ul> <li>Assists with coordinating and communicating Marketplace or carrier issues that need correcting (to prevent policy lapses). Such as: </li></ul> <p>Ø Auditing client marketplace activities for plan changes, terminations and re-enrollments; and</p> <p>Ø Monitoring for information updates (Ex. Income verification).</p> <p>o Store all other necessary documents in one place for all parties to access and generate enrollment reports; and</p> <ul> <li>Submits assessments/pre-enrollment paperwork before Open Enrollment starts </li></ul> <p>o Assess resources, conduct training for staff (within the department) and build partnerships between July - August,</p> <p>o Focusing on specific plan considerations for People Living with HIV (PLWH);</p> <p>o Understand that open enrollment lasts for 45 days (November 1st through December 15th) for coverage that begins January 1st (via HealthCare.gov) and that it is necessary that planning / preparation takes place beginning of July 1st.</p> <p>o Develop a work plan to accomplish open enrollment preparation and enrollment activities (with the understanding that the ACA coordinator is the primary person enrolling patients);</p> <p>o Assessing all patients who are not on ACA if he/she meets criteria for enrollment; and determining enrollment appointments with Client.</p> <ul> <li>Obtain Certification as a Certified Application Counselors (CAC's) before enrollment period begins (https://marketplace.cms.gov) website for updates </li></ul> <p>Case Monitoring (ongoing)</p> <ul> <li>Maintain an active spreadsheet in real-time and case monitor/ case manage clients on the list to avoid double dipping by enrolled clients. This includes: </li></ul> <p>o Ensuring that clients do not have private or employer-based insurance;</p> <p>o Ensuring that clients are not receiving VA benefits;</p> <p>o Ensuring that clients are not enrolled into Medicaid/Medicare.</p> <ul> <li>Case-manage and track all applications until eligibility/coverage is determined </li></ul> <p>o Document in Electronic Medical Record (EMR) and spreadsheet daily activities.</p> <ul> <li>Respond and reach out to guide and support individuals and families of diverse backgrounds and facilitate enrollment in appropriate public health insurance programs - meet the clients where they are. </li><li>Collaborate with other Ryan White team members (Ex. Case managers, Referral specialist) and the Pharmacy team, in ensuring that all insurance-related issues are addressed and resolved. </li><li>Provide a monthly report of ACA data concerning compliance issues. Such as: sliding fee plans, missing upcoming appointments, and medication adherence. </li><li>Documentation in Electronic Health Records </li><li>Processing Premium Payments with Insurance Carriers and Finance </li><li>Update and submit Eligibility/Payment templates sent by both Insurance carriers. </li><li>Templates must follow the instructed guidelines; </li><li>Templates should be submitted within the stipulated dates. </li><li>Pharmacy and Medication - respond to inquiries by the in-house pharmacists inquiries via EMR </li><li>Monitor Patient Switches from AIDS Drug Assistance & Patient Assistance Programs to Affordable Care Act (ACA) in house pharmacies program </li><li>Ensure that patients on AIDS Drug Assistance Program & Patient Assistance Programs successfully get screened for meeting criteria to switch to ACA in-house pharmacies program (collaborate with pharmacy and case management; must report status at daily huddle meetings </li></ul> <p>Referrals</p> <ul> <li>Uses good judgment when providing patient care. </li><li>Maintains confidentiality of all pertinent patient care information to assure patient rights are protected. </li><li>Observes courtesy standards through use of verbal amenities, pleasant facial and body expressions and pleasant voice tone when in contact with co-workers, providers, patients and visitors. </li><li>Communicates appropriately and clearly to patients and co-workers. </li><li>Works effectively with people regardless of their age, gender, race, ethnicity, religion, or job type. </li><li>Maintains composure when confronted with job stress or emergency situations. </li><li>Adapts well to change in the work place </li><li>Consistent and concise lines of authority and responsibility are maintained. </li><li>Responsibilities will include making medical referral appointments to agencies/entities outside of Eau Claire Cooperative Health. </li><li>Maintains confidentiality of patients, staff and department information at all times </li><li>Maintain documentation within 24-72 hours of encounters </li><li>Understand that job functions are directly linked to the Ryan White (RW) Legislation, including Policy Clarification Notice (PCN) #16-02 (Revised 10/22/18). This includes awareness of the scope of coverage under the Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program (RWHAP)-Parts A, B, C, D, and F-where funding supports direct care and treatment services. </li><li>Additional relevant guidance includes PCN 21-02 and PCN 15-02. </li><li>Participate in Continuous Quality Improvement (CQI) activities to support program efficiency and improve client outcomes. </li><li>Perform other related duties as assigned to ensure the smooth and effective operation of the department. </li></ul> <p>Knowledge, Skills and Abilities</p> <p>Exceptionally strong written and verbal communication skills</p> <ul> <li>Strong attention to detail and the ability to manage multiple projects, establish workload priorities, and meet deadlines </li><li>Solid interpersonal skills along with the ability and willingness to respect and value the differences and perceptions of different groups/individuals </li><li>In addition, strong sociability skills are important to engage others in conversation and build relationships as well as to actively participate while interacting with others </li></ul> <p>Physical Demands</p> <ul> <li>Prolonged periods sitting or standing </li><li>Must be able to lift up to 25 pounds. </li><li>Be able to sit, stand, stoop, squat for extended periods of time throughout the day. </li><li>Standing or walking for extended periods throughout the day. </li></ul> <p>Company Conformance Statement:</p> <p>In the performance of their respective job assignments all employees are expected to conform to the following:</p> <ul> <li>Cooperative Health's policies and procedures. </li><li>Cooperative Health's confidentiality and professional provisions </li><li>Cooperative Health's compliance program </li><li>Cooperative Health's standards of conduct </li></ul> <p>Cooperative Health provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Cooperative Health complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.</p>