Eligibility Specialist Jobs

Summary
We are searching for an Eligibility Specialist -- someone who works well in a fast-paced setting. In this position, you will ensure that member eligibility data is accurate and complete by auditing, validating, reconciling, and updating the data in the claims processing system. You will provide a comprehensive and timely response to member eligibility inquiries from internal and external stakeholders.
Skills & Requirements

• Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption
• A bachelor’s degree may substitute for the years of required work experience
• High school diploma or GED required
• 2 years previous experience working at or with an HMO or MCO organization required
• Bachelor’s degree preferred

Job Duties & Responsibilities

• Research and resolve member eligibility issues thoroughly, timely, and accurately
• Review and respond to member eligibility inquiries within established timeframes from both internal and external stakeholders
• Respond timely to member eligibility inquiries from internal and external stakeholders
• Manually update member eligibility data in the claims processing system using multiple sources for reference, including applications, databases, and reports
• Address member eligibility issues submitted via the Eligibility group email boxes and Macess service forms, as well as reports submitted via a secure FTP site
• Ensure member eligibility data is processed in accordance with Health Plan and department policies and procedures, as well as State guidelines and requirements
• Validate and reconcile member eligibility data in the claims processing system after each daily and monthly file load to ensure it matches the data received from the state