Job Specification Details

Professional and technical health care eligibility and customer service work performed in the matrixed Health Access Eligibility and Enrollment Unit for Vermont Health Connect and Green Mountain Care. These positions determine applicant eligibility for Vermont's health care programs: Medicaid, Dr. Dynasaur, Healthy Vermonters, VPHARM, and Vermont Health Connect, in addition to providing ongoing customer service to Vermonters enrolled in these programs and qualified health plans (QHPs) within the Tier 2 call center. This position is responsible for processing applications and making eligibility determinations using the following systems: Siebel, ACCESS, and the Vermont Health Connect portal. A large portion of the work required for this position relies upon the employee's ability to use their independent judgement to make a determination based on complicated policy and rules research. Work is performed under the supervision of a Healthcare Service Supervisor or the unit's Assistant Director.

Incumbents of this job class will experience fluctuations in assigned duties in response to the organization's needs, program changes, special project needs, and changes in experience levels.

Handle large volume of incoming and outreach phone calls to customers regarding their coverage and/or benefits results, which may lead to de-escalating conversations. Reviews and enters applications for Vermont's health care programs to determine eligibility and complete enrollment and plan selection. Processes change of circumstances/change of information with extreme attention to detail to ensure accurate processing. Customer outreach is conducted regarding status of application and required information needed to complete the process, requiring a thorough understanding of internal and external business processes to assist in determination of the correct path of escalation for a case, in addition to a thorough understanding of policies and guidelines for multiple federal healthcare policies.

Prioritization of high priority and escalated cases, ability to navigate through and interpret data from various systems such as Siebel, ACCESS, OnBase, and Benaissance in order to extract necessary information and history of particular cases. This complex review and recon process is vital to proper resolution of each issue that needs to be solved. Worker must also be able to run discrepancy reports.

VT Healthcare Service Specialists will be enrolling clients in Dr. Dynasaur, Dr. Dynasaur for pregnant women, VPHARM for prescription coverage, Blind-Aging-Disabled Medicaid, Vermont Health Connect, Immigration Medicaid, Transitional Medicaid, Working People with Disabilities, and Assisted Community Care Services. All enrollments must be done in a timely manner in order for customers to receive services. Administrative case management duties such as: ensuring information is accurate according to document protocols, processing of return mail, pharmacy applications, quarterly reports, and verifications and sending out mailings is also a critical component of the job.

Duties are performed in an office setting. Workload is consistently heavy with constant need for prompt and accurate decision making. Incumbents must be able to function independently, prioritize their own work and multi-task effectively. Private means of transportation should be available for necessary travel to training and/or meetings. Applicants may provide a variety of challenges including but not limited to highly emotional conditions (i.e., irate customers, inability to communicate, attempts at falsification, and total discouragement). Work outside of typical business hours may be expected.

Knowledge of and ability to apply computer skills such as database management, CRM (customer relationship management) software utilization, and Microsoft Office programs such as Word, Outlook, and Excel.

Must have the ability to research and use independent judgement to make a determination or choose correct escalation path.

Ability to stay organized and work effectively independently and in a team setting.

Must be able to comprehend the varying levels of priorities between cases and escalate based on medical and/or financial needs.

Ability to communicate in a professional manner with customers who are upset and emotional about their coverage and/or benefits results.

Ability to explain complex instructions, regulations, and policies in a clear and easy-to-understand way.

Effective keyboarding skills which will enable processing of large volumes of applications and other documents in timely manner.

Working with, and communicating to, culturally diverse groups of individuals and accommodating their different needs and viewpoints.

Ability to process large volumes of work accurately while under strict time constraints.

Working knowledge of healthcare programs and the basic philosophy underlying each.

Ability to read, interpret and apply complex rules, regulations, policies, and procedures.

Ability to multi-task under strict time restraints.

Ability and skill in arithmetic computation.

Ability to communicate effectively verbally and in writing.

Ability to provide leadership within the framework of the four key practices of the Agency of

Human Services: customer service, holistic service, strengths-based relationships, and results orientation.

One (1) year of experience in a customer service environment and using computer programs. 

OR 

Six (6) months experience as a Vermont Healthcare Service Specialist I (VHSS I). 

One (1) year of experience in a customer service environment or call center environment using computer programs including data entry and the ability to explain policies/procedures or rules/regulations

Experience with research and review of healthcare services or similar field
 

Candidates must pass any level of background investigation applicable to the position. In accordance with AHS Policy 4.02, Hiring Standards, Vermont and/or national criminal record checks, as well as DMV and adult and child abuse registry checks, as appropriate to the position under recruitment, will be conducted on candidates, with the exception of those who are current classified state employees seeking transfer, promotion or demotion into an AHS classified position or are persons exercising re-employment (RIF) rights.