Benefits Investigation and Eligibility Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Confirm active coverage for primary, secondary, and tertiary insurance, including member details, demographics, effective dates, plan type, payer information, and coordination-of-benefits requirements.

• Utilize payer portals, electronic eligibility tools, and direct communication with payers to verify coverage and address insurance discrepancies.

• Reach out to patients and provider offices to gather missing or corrected insurance details and escalate unresolved matters.

• Investigate benefits related to genetic and molecular diagnostic services, including deductibles, copayments, coinsurance, out-of-pocket costs, benefit limitations, and network requirements.

• Identify necessary prior authorizations, notifications, referrals, medical records, and other payer stipulations.

• Direct cases to the appropriate team with comprehensive supporting information.

• Accurately document benefit findings, payer representatives, reference numbers, call dates, portal results, and follow-up actions.

• Clearly communicate eligibility and benefit findings without providing coverage guarantees.

• Independently manage assigned work queues, prioritize urgent cases, follow up within established turnaround times, and meet productivity and quality standards.

• Research and resolve routine issues, review work for accuracy and completeness, maintain auditable documentation, and escalate payer, system, or policy issues as needed.

• Engage in training, quality reviews, and workflow enhancements.

• Safeguard patient, client, financial, and company information according to HIPAA and Baylor Genetics policies.

• Perform additional job-related duties as assigned.

⛳️ Requirements

• High school diploma or equivalent qualification.

• Over 2 years of experience in healthcare insurance verification, benefits investigation, patient access, revenue cycle, or a related role.

• Proficient understanding of commercial insurance, Medicare, Medicaid, and managed care plans.

• Experience utilizing payer portals, electronic eligibility tools, and healthcare or revenue cycle systems.

• Capacity to work independently, research issues, make informed decisions within established guidelines, and escalate when necessary.

• Strong problem-solving abilities and capacity to resolve incomplete, conflicting, or ambiguous insurance information.

• Exceptional attention to detail and accuracy in data entry, documentation, and follow-up processes.

• Excellent written and verbal communication skills with a professional, patient-focused demeanor.

• Ability to manage multiple cases and priorities within a production-driven environment.

• Capability to appropriately handle protected health information and confidential financial data.

• Preferred: Associate degree in healthcare administration, business, or a related discipline.

• Preferred: Background in diagnostic laboratory, genetics, molecular diagnostics, pathology, or specialized healthcare.

• Preferred: Familiarity with Quadax, Salesforce, clearinghouses, payer portals, or similar systems.

• Preferred: Understanding of prior authorization workflows, payer medical policies, and patient financial responsibilities.

• Compliance with HIPAA, Baylor Genetics policies, and relevant payer and regulatory standards.

🏝️ Benefits

• Remote work arrangement.

• Reasonable accommodations provided in accordance with applicable law.

• Commitment to an equal opportunity and inclusive workplace.

• Opportunities for training, participation in quality reviews, and workflow improvement initiatives.