Job Summary:

Reporting to the Claims Supervisor, the Eligibility Specialist is primarily responsible for verifying and confirming member eligibility and notifying health plans when appropriate.

Essential Job Functions:

Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position.

• Verify member eligibility between eligibility uploads and add/update member profiles.
• Confirm health plan enrollment by researching eligibility information online with various carriers and update systems with supporting documentation.
• Research, investigate and resolve member eligibility discrepancies.
• Document, coordinate and verify primary insurance carriers and/or other health coverage that members may have.
• Confirm covered benefits when member has OHC.
• Notify health plans when OCH is identified in order to better coordinate benefits.
• Identify inappropriately enrolled members upon new member enrollment and take necessary steps to correct their eligibility status (i.e. – appropriate aid codes, out-of-area, etc.)
• Performs other related duties consistent with the scope and intent of the position.
• Regular attendance.

Other Functions:

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.

Competencies

• Word processing and computer experience required.
• Microsoft Off Suite experience required.
• Ability to maintain production level and quality goals.
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking skills.
• Ability to solve mid-level problems with minimal supervision.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Demonstrated excellence in organization.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need to know basis.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately, thoroughly and effectively.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must be able to accurately type 35 WMP.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Supervisor Responsibility

Education and Licensure

Travel

Work Environment

This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.

Mental and Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands to finger, handle, or feel; and reach with hand and arms.

The employees is frequently required to sit and/or stand; climb or balance; and stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

Experiences frequent interruptions; required to meet inflexible deadlines; requires concentration and attention to detail; requires a high level of organizational and prioritization skills.

Required to sit and/or stand for prolonged periods; exposed to visual display terminal for prolonged periods; dexterity and precision required in the operation of a computer.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.