Lead Benefits Eligibility Specialist

Description

The Lead Eligibility Specialist is responsible for ensuring the eligibility team is adept in the tasks of verifying 

insurance eligibility and benefits, addressing insurance related patient concerns, providing Federal 

Funded Programs to include but not limited (Ryan White & SAMSHA, etc.), other PIHC services and 

completing required eligibility with clients who qualify, advise patients of their financial obligations. This 

position may occasionally provide variety of Front Office administrative duties, including but not limited 

to answering and directing phone calls, greeting patients, collecting copayments, maintaining patient 

accounts by obtaining, recording, and updating personal and financial information

Requirements

JOB DUTIES & RESPONSIBILITIES:

This position description should not be interpreted as all inclusive, it may be updated as funding 

deliverables, clinical/agency guidelines, and CDC guidelines change. It is intended to identify the major 

responsibilities and requirements of this position. The incumbents may be requested to perform jobrelated responsibilities and tasks other than those stated in this position description.

Essential Duties, Tasks, and Responsibilities:

• Coordinate eligibility team training, efficiency, and productivity for the following tasks: 

o Verify insurance on scheduled patients to ensure eligibility and benefits are 

effective in order for accurate timely claim submission and payment.

o Input demographic information, billing information and insurance into medical 

management system.

o Process intake forms and verify insurance benefits and or financial obligation for 

all new clients.

Adrienne White

o Utilizes the online eligibility verification system, and/or may have to contact 

Payer directly via telephone, and/or access payer website.

o Assists client with any health care plan questions, concerns or issues to ensure 

that any problems are identified and necessary corrections are made in time to 

prevent or minimize delays in the client receiving coverage.

o Communicate with patient regarding patient’s insurance benefits, financial 

responsibility per sliding fee schedule, and to ensure Front Office is able to 

collect moneys such as copays.

o Conduct financial assessments for designated patients as described in the policy 

and procedure. 

o Verify insurance benefits for all new patients, upon change of insurance 

coverage, and/or an annual basis. Document covered benefits on the insurance 

verification form. 

o Educate clients regarding all financial and insurance benefits, government funds, 

grant, and drug reimbursement programs. Ensure all requirements are met.

o Assist in billing and collection of patient accounts.

o Collects all supporting documentation for Federal funded services eligibility and 

ensure that all documentation is uploaded in the system

o Assist patient in managing the sliding fee scale and determining annual cap on 

charges as required by Ryan White program

o Complete Ryan White annual certification processes to ensure that clients are 

eligible to receive services

o Contact and ensure that clients receiving Federal funded services are aware of 

the dates/times that their certifications are scheduled and ensure that clients 

are reminded of the documentation required of them for certification/eligibility.

o Collect digital submissions of consents and eligibility documents and attach to 

electronic medical record.

• Ensure eligibility staff are knowledgeable and have experience with all payer types: 

Commercial, Medicare, Medicaid, HMO, etc. 

• Review and monitor eligibility compliance reports (E2Fulton, Insurance Denials, Financial 

Assistance Access, Continuum etc.) to identify opportunities for process improvement 

and/or additional staff training. 

• Communicate with other departments on the behalf of the team to improve daily 

coordination of tasks and the patient experience. 

• Cultivate a work environment that encourages teamwork, effective communication, and 

accountability with all PIHC staff.

• Encourage the use of exemplary customer service skills amongst staff when interacting 

with patients.

• Performs all other related duties as assigned.

MINIMUM QUALIFICATIONS & EXPERIENCE :

A high school diploma or GED Equivalent and one year of clerical experience in a medical environment. 

College degree preferred.

And

Minimum three years’ experience in Healthcare Customer Services, insurance verification, and/or 

experience in providing Federal funded services. Experience in medical records and/or medical data