Basic Job Description: The Eligibility Specialist is responsible for managing all aspects of patient billing, insurance verification, claims submission, and payment posting. This position ensures accurate and timely processing of claims while maintaining compliance with regulatory requirements and company policies. The specialist serves as the primary contact for patients, insurance companies, and internal staff regarding billing inquiries, denials, and account resolutions.
Essential Duties and Responsibilities
- Verify consumer insurance coverage and benefits prior to appointments.
- Prepare, review, and submit accurate insurance claims (electronic and paper) in a timely manner.
- Follow up on unpaid or denied claims, resolve discrepancies, and resubmit as needed.
- Process adjustments and reconcile discrepancies.
- Ensure compliance with federal, state, and payer regulations (HIPAA, Medicare, Medicaid, Managed Care Organizations).
- Maintain detailed documentation of billing activities.
- Collaborate with clinical and administrative staff to resolve billing or coding issues.
- Generate billing and financial reports as requested by management.
- Perform duties in accordance with company policies, procedures, and applicable regulations.
- Other duties as assigned by leadership.
Requirements
- High school diploma or equivalent; associate degree preferred.
- Certification in medical billing preferred.
- 2+ years of billing/insurance experience.
- Knowledge of medical terminology and insurance processes, specifically with Managed Care Organizations.
- Proficient in English (oral and written); active listener with excellent communication skills.
- Proficient in billing software and electronic health records (EHR).
- High proficiency in Microsoft 365 applications and general systems aptitude.
- Tech-savvy, good typing skills, and data entry experience.
- Outstanding ability to work independently to achieve results. Must originate, plan, adapt, and invent to accomplish tasks.
- Ability to set and maintain priorities when dealing with multiple demands and interruptions.
- Strong analytical and problem-solving skills.
- Ability to multitask, interpreting on-going problems and suggesting possible solutions.
- Ability to handle confidential information with professionalism and discretion.
