Eligibility Analyst

Role Overview

• Establishes and maintains processes regarding billing and claims processing, insurance verification and authorization, revenue cycle management, compliance and documentation, as well as customer service and issue resolution.
• Reconciles and solves issues to ensure accurate billing, facilitate smooth revenue flow, maintain compliance, and provide satisfactory customer experiences.
• Reviews and analyzes applications, forms, and supporting documentation to verify individuals' eligibility for healthcare programs or insurance coverage.
• Applies eligibility rules and regulations when evaluating information submitted by customers in support of initial or continuing eligibility determination.
• Compiles and evaluates information, calculating eligibility factors, and ensuring consistent and fair eligibility determinations.
• Escalates eligibility issues and updates member records in the appropriate database(s) to ensure accurate data.
• Conducts basic quality audits of eligibility uploads to ensure data integrity is clean, accurate, and consistent with specifications.
• Communicates regulations, rules, and policies to clients and apprises them of their rights, responsibilities, and eligibility for participation.
• Educates customers on basic program services and eligibility requirements.
• Coaches more junior colleagues in intellectual property techniques, processes, and responsibilities to help optimize eligibility reviews.
• Assigns tasks, sets performance goals, conducts performance evaluations, and provides training and educational development opportunities to team members.

Requirements

• 2+ years customer service or client-facing experience in a fast-paced environment
• Basic awareness of problem solving and decision making skills.
• Microsoft Office working experience.
• 3+ years in eligibility or other relevant background preferred.
• Proficiency in processing accurate and timely Eligibility data.
• Experience in EDI (Electronic Data Interchange).
• Understanding of the PBM industry.
• Experience in a healthcare client facing role.
• Knowledge of ANSI X12 834 Data Documents.
• Familiarity with RxClaim and/or AS400.
• Microsoft Excel experience.

Benefits

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs