Eligibility Specialist

This is a fully remote position, open to applicants in Illinois, +4 more states.

📋 Description

• Conduct insurance eligibility and benefit verification for both new and existing learners.

• Assess and confirm eligibility results, member status, effective dates, plan details, benefits, limitations, exclusions, and payer requirements.

• Determine primary and secondary coverage and coordination-of-benefits aspects.

• Validate provider and service-location network status while identifying insurance-related obstacles.

• Ascertain requirements prior to service initiation, including assessment or treatment authorization necessities.

• Collaborate with Intake, Clinical Operations, and Authorization teams to address requirements, missing information, and barriers.

• Initiate and manage assessment authorization requests.

• Track authorization requests through to determination and perform complete payer follow-up.

• Record and communicate approved authorizations.

• Acquire, document, and maintain insurance and authorization records in CentralReach and other specified systems.

• Perform eligibility and benefit rechecks when there are changes in coverage or when validation is necessary.

• Direct insurance modifications and authorization-impacting issues to the appropriate team.

• Examine automated eligibility and insurance transactions and resolve exceptions that require manual intervention.

• Recognize recurring eligibility, payer, and automation challenges, and inform the Supervisor about trends and opportunities for process improvement.

• Utilize Solum Health, CentralReach, and other designated systems in accordance with workflows and payer requirements.

• Engage in testing, training, and the enhancement of eligibility and intake insurance workflows.

⛳️ Requirements

• A high school diploma or equivalent is required.

• An Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or a related field is preferred.

• At least one (1) year of experience in insurance, eligibility verification, medical billing, prior authorization, or a related field is preferred.

• Comprehensive understanding of health insurance eligibility, benefits, coverage limitations, exclusions, deductibles, and out-of-pocket requirements.

• Ability to accurately interpret insurance benefits and identify requirements that affect access to behavioral health services.

• Strong knowledge of eligibility verification, benefit coverage, and assessment authorization requirements.

• Excellent attention to detail and accuracy.

• Ability to identify discrepancies, coverage challenges, and potential barriers, and escalate them as necessary.

• Outstanding organizational and time-management abilities.

• Strong written and verbal communication skills.

• Proficient in navigating payer portals, electronic eligibility systems, CentralReach, Solum Health, and other technology platforms.

• Capable of working independently, exercising sound judgment, following established workflows, and recognizing when escalation is needed.

• Ability to collaborate effectively with Intake, Clinical Operations, Credentialing, and Authorization teams.

• Ability to sit for extended periods, occasionally stand, walk, use a keyboard, and lift or move up to 25 pounds.

• Vision requirements include close vision, distance vision, depth perception, and the ability to adjust focus.

🏝️ Benefits

• Fully remote work arrangement.