Eligibility Analyst Resume Sample

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Estrella Becker
19235 Daron Mission,  Los Angeles, CA
+1 (555) 576 4778

Work Experience


Eligibility Analyst Senior Assoc
03/2017 - PRESENT
Los Angeles, CA
  • Technical expertise of ESI’s systems and processes
  • Understand and be able to use CMS Guidance
  • Continuously strives to provide superior products and customer service
  • Expresses oneself in an open and honest manner
  • Demonstrates self-awareness and embraces feedback
  • Setup client eligibility rules for CIGNA’s new online enrolment tool and provide support to both the team and the client during training
  • Conduct thorough, in-depth interviews and evaluate patient’s case for potential eligibility for Medical Assistance Programs, Market Place Insurance and any applicable Purchase of Medical Care programs
  • 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
Medicaid Eligibility Analyst
11/2013 - 10/2016
Chicago, IL
  • Handle multiple priorities and deadlines, work independently, as well as, in a team environment and proactively with internal and external partners
  • Detail oriented, ability to multi task, and ability to use multiple applications
  • Strong communication skills; written, verbal and listening skills
  • Accurate interpretation, documentation, and set up of client specific vendor structure to accommodate employer group and business rule with external vendor
  • Review and translate vendor file layout working with internal teams to ensure accuracy of vendor specifications and structure
  • Provide a high level of expertise with knowledge of products and system configuration as they pertain to benefits, industry standard and system functionality
  • Accurately maintaining and following all vendor procedure documents
  • Work closely with external and internal partners to accurately resolve error reports in a timely manner
  • Work closely with external and internal partners to ensure testing of all vendor files during implementations, renewals, and change orders
Eligibility Analyst Entry
10/2009 - 08/2013
Chicago, IL
  • The Medicaid Eligibility Analyst has the ability to act for the individual and exercise the individual’s rights
  • 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
  • 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
  • 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
  • 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 managing the electronic eligibility files for assigned cases, including manual loading and updating from system fall-out reports
  • Analyzes formats that are customized directly by the client or vendor
  • Accountable for identifying any file formatting or data integrity errors, and working with the business leads for resolution
  • Provides recommendations to minimize errors or fallout

Education


Grand Valley State University
2004 - 2009
School's Degree in Computer Science

Professional Skills


  • Evaluate the impact of proposed changes and initiatives, including ACA and other legislative, regulatory, or management policies on health programs, policies, and operations. Participate in, and perform research activities to support policy, eligibility, ACA, program, and evaluation activities
  • Strong interpersonal skills with excellent communication skills
  • Proven track record in a role requiring both verbal and written communication skills
  • Good written and verbal communication and customer services skills
  • Prior group eligibility enrollment experience preferable
  • Prior group eligibility enrollment experience
  • Strong customer focus with developed problem-solving abilities and a proactive approach to proposing/implementing process improvements

How to write Eligibility Analyst Resume

Eligibility Analyst role is responsible for customer, communications, software, training, database, mac, security, research, modeling, insurance.
To write great resume for eligibility analyst job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Eligibility Analyst Resume

The section contact information is important in your eligibility analyst resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Eligibility Analyst Resume

The section work experience is an essential part of your eligibility analyst resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous eligibility analyst responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular eligibility analyst position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Eligibility Analyst resume experience can include:

  • Excellent customer service/people skill and experience are required
  • Call Center experience required
  • Data entry experience required
  • Liaising with external departments and clients to manage expectations and queries
  • Participates on special projects as assigned, including regression testing, apprenticeship opportunities, etc
  • Ownership of the vendor inquiry mailbox, including review , support, analysis, and follow through in a timely manner of all inquires

Education on an Eligibility Analyst Resume

Make sure to make education a priority on your eligibility analyst resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your eligibility analyst experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Eligibility Analyst Resume

When listing skills on your eligibility analyst resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical eligibility analyst skills:

  • Utilize strong time management skills to manage a high volume of accounts and to prioritize individual workflow
  • 1-3yrs. experience in related experience
  • Experience in managed care contracting or the pharmaceutical industry
  • Strong Knowledge of Word, including mail merges
  • Medicare customer service or enrollment experience – 2 years
  • Understanding of Insurance Industry

List of Typical Experience For an Eligibility Analyst Resume

1

Experience For Medicaid Eligibility Analyst Resume

  • Responsible for procedure documentation as needed for both new business processing and ongoing service within Long-Term Care
  • Assist with team logistics- team meetings/ identifying resources to support team requirements
  • Communicates with team members, willing to help other team members at a moment’s notice to ensure reports are worked in a timely manner
  • Consistently meet or exceed job expectations to maximize positive outcomes
  • Provide training, assessment, coaching and technical support; Act as a technical resource to operational management and staff on the appropriate interpretation of accounts receivable, financial data and federal and state Medicaid guidelines
  • Coordinate and mentor staff regarding federal and state rules and regulations, Medicaid guidelines,accounts receivable and financial systems, analysis, reports and policies/procedures
  • Identify process improvements, including staff education/training, operational workflow modifications, system enhancements and work with appropriate personnel to implement improvements
2

Experience For Eligibility Analyst Senior Assoc Resume

  • Provide training, coaching and technical support with preparation of appeal briefs, witness interviews and compilation of evidentiary testimony for all levels of appeals including but not limited to local, state, Chief Hearing Officer, Superior court and ALJ as needed
  • Troubleshoot and liaison with internal and external customers to resolve Medicaid related issues
  • Office of Hearings and Appeals
  • Perform quality reviews and analysis to support internal controls and unit performance
  • Maintain all functions and responsibilities of the Medical Assistance counselor
  • Provide support for main MAC hub as well as 4 additional locations
3

Experience For Eligibility Analyst Associate Resume

  • Upload and Audit client membership information electronically, analyse data and raise queries with clients, brokers and 3rd party flex providers
  • Complete annual renewal membership audits, online set up and mailings within agreed client SLA’s
  • Support the Membership helplines and inboxes (Online Helpdesk, Internal fast track and external Client)
  • Raise requests with the IT (Web) Team via internal system and manage expectations
  • Liaise directly with clients / billing administration / account managers / sales support as necessary to ensure the accuracy of information received and recorded
4

Experience For Benefits Eligibility Analyst Resume

  • Analyze, organize, and manage to all returned mail, making modifications to the administrative systems
  • Perform quality review of all materials as needed
  • Download, set up and log HDX reports that have been assigned to the Eligibility Analyst for the week
  • Thorough knowledge of TeamHealth billing directives and process all claims according to these directives. The goal is to insure that the HDX reports are correctly worked in a timely manner
  • To make sure that the Eligibility Analyst have all current and up to date Job Aids and Policies. These are to be accessed on the AKBC “S” drive
  • Communicates with the Director of Reimbursement on the progress of projects and assignments and progress toward completion on a timely basis
5

Experience For Eligibility Analyst Entry Resume

  • Consistently meet and maintain the QA and production standards
  • Evaluates eligibility and plan level changes received and applies the correct contract/benefit provisions, business rules and state/federal legislative requirements
  • Provide justification for strategic and technical action plans and governmental regulation interpretation is scrutinized on a routine basis by a contracted Medicaid Attorney
  • Benefit Eligibility experience

List of Typical Skills For an Eligibility Analyst Resume

1

Skills For Medicaid Eligibility Analyst Resume

  • PC literate Solid knowledge of Excel
  • Organise, prioritise and manage tasks to meet individual and team production standards
  • Experience with PC-based software programs and automated database management systems (Excel, Access, PowerPoint, SAS, SQL, etc.)
  • Assesses eligibility requirements and determines if/when Evidence of Insurability is required and acts appropriately based on established procedures
  • Actively foster a respectful work environment by modeling positive behaviors and promoting a team oriented environment
  • Support the UK membership database team ensuring all information is updated correctly for client invoicing
  • Assess patient's continuing care needs and determine correct program and certification period to minimize patient deductible and maximize entity reimbursement
2

Skills For Eligibility Analyst Senior Assoc Resume

  • Communicate and advise patients on complex financial concepts and procedures of applying for Medicaid
  • Use of Microsoft Excel functions and data formatting
  • Proactively follows up with customers for missing information needed to process the requested change to prevent interruption of services
  • Strive for first contact resolution through taking ownership of the contact from start to finish
  • Analyse and manage the membership files ensuring accurate data is provided and recorded
  • Maintain and audit an accurate membership database based on enrolment criteria, entering eligibility information within client SLA’s
  • Provide online support to our clients and members aiming for first time resolution
  • Provide client reports as and when required ensuring data has been downloaded correctly and is issued within Cigna guidelines
  • Proficiency with MS Office recommended
3

Skills For Eligibility Analyst Associate Resume

  • 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
  • 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
  • Coordinate and facilitate the completion of the Medicaid application
  • Gather and provide necessary verifications to establish Medicaid 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
4

Skills For Benefits Eligibility Analyst Resume

  • 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
  • Present patient case, examine and cross examine witness', 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
5

Skills For Eligibility Analyst Entry Resume

  • Maintain detailed knowledge of company products and New Business processing procedures
  • Assists in testing new applications and/or systems
  • Knowledge of Microsoft Office products, including Excel, Access, Word and Outlook
  • Serve as an educational resource on Medicaid issues for patients, Social Workers, Physicians, Clinic and Admissions personnel
  • Exercise discretion and independent judgment under stressful conditions handling several tasks simultaneously while providing consistent follow through and decision making to insure timely completion
  • Clerical experience with proficiency with PC and software programs such as Word, Excel
6

Skills For Eligibility Analyst Senior Associate Resume

  • Fluent in Spanish/English - Bilingual
  • Documents and works with internal partners and external vendors to resolve system problems
  • Analyzes data and reconciles eligibility for accuracy
  • Thorough technical knowledge of assigned products
  • Awareness of Data Protection
  • Higher Grade English or equivalent
  • Work under own initiative and can work well under pressure
7

Skills For Customer Membership & Eligibility Analyst Resume

  • Manage multiple tasks simultaneously in a fast-paced, customer-oriented environment
  • Accountable for providing consistent customer service to customers on processing eligibility related changes (open enrollment changes, adding members/dependents address changes, salary changes, COBRA enrollments, terminations, waivers, etc) to ensure billing statements are accurate and benefits are administered properly for accurate claims payment
  • The Eligibility Analyst is responsible for
  • Evaluates eligibility changes received and applies the correct contract/benefit provisions, business rules and state/federal legislative requirements
  • Demonstrates strong decision making skills and thoroughly understands the CEPS processes and workflows needed for plan maintenance and understands when they need to be applied. Escalates situations appropriately based on established authority levels
8

Skills For Senior Eligibility Analyst Resume

  • Answers questions, troubleshoots and resolves potential problems, including technical and workflow issues
  • Completion of company training program required
  • Assess patient continuing care needs and determine correct program and certification period to minimize patient deductible and maximize entity reimbursement
  • Actively participates in team meetings and shares information and best practices with the team
  • Supports departmental goals through demonstrating high standards of professionalism and service while maintaining consistent accuracy to provide a positive customer experience
  • Consistently meets departmental standards for quality and production
  • Adheres to schedules and uses Time Tracker correctly to ensure accurate productivity is captured
  • Potentially work a shift until 6:00 pm
9

Skills For Benefit Eligibility Analyst Resume

  • Work within a large team
  • Legal liability involved for the counselor who is responsible to the county/state for the accuracy of information and actions taken on behalf of the patient
  • The personal representative stands in the shoes of the individual and has the ability to act for the individual and exercise the individual's rights
  • Coordinate, facilitate and/or complete Medicaid application
  • Gather and provide necessary verifications to establish Medicaid eligibility via direct contact with patient and direct or indirect contact with 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
10

Skills For Eligibility Analyst, Ceps Resume

  • Follow-up with patient and the Department of Social Services to insure all pertinent information has been provided relevant to the Medicaid application
  • Justification for strategic and technical action plans and governmental regulation interpretation is accomplished in consultation with Medicaid Attorney
  • Coordinate FTP Transmission setup to vendor
  • Liaise and coordinate with internal customers to ensure a one team approach
  • Pro-actively identify departmental improvement opportunities and recommend solutions
  • Carry out other ad-hoc tasks as required, to meet business needs
  • When approved, the Lead Medical Assistance Counselor is responsible for entering pertinent information into the hospital system and closely monitoring authorization dates and deductible amounts applied to patient accounts
  • Serve as an educational resource on Medicaid issues for patients,Social Workers, Physicians, Clinic and Admissions personnel
  • Adhere to all Duke, PRMO and departmental policies and procedures

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