Eligibility and Benefits Specialist Full Time

Job Summary

The Eligibility & Benefits Specialist plays a crucial role in ensuring patients can access the care they need by verifying insurance benefits and eligibility before admission. With precision and attention to detail, this role reviews patient insurance policies to confirm active coverage, identify covered services, and understand financial responsibilities such as deductibles, co-pays, and out-of-pocket maximums. Specialists proactively verify eligibility with insurance companies to prevent claim denials, delays, and costly errors. They also review visit limits, restrictions, benefit caps, and coordinate verification for secondary insurance when applicable.

Essential Functions

• Serves as key team member of the new Central Access and Authorizations Team (CAAT), focused exclusively on eligibility and benefit verification.
• Actively works a queue of patient referrals and references multiple sites to conduct E&B checks, Medicare status and entitlement, citizenship status, and any worker’s compensation details.
• Accesses Medicare Common Working files and calculates Medicare days.
• Accesses other insurance verification portals to determine benefits and eligibility coverage.
• Verifies patient insurance coverage and eligibility for admission services with primary and secondary payors.
• May assist in calling hospital (i.e., case management, nursing, etc.) for admissions dates and SNF dates.
• Aids in the coordination of benefits, including outreach to patient and/or family to obtain and verify benefits information.
• Obtains revocation letters where needed and appropriate to secure proper funding and reimbursement.
• Reviews and documents benefit details, including deductibles, co-pays, co-insurance, and out-of-pocket maximums.
• Identifies coverage limits, restrictions, benefit caps, and authorization requirements.
• Confirms policy effective dates, termination dates, and coordination of benefits when applicable.
• Accurately enters benefits data into the appropriate systems in a timely manner.
• Communicates benefit details and potential patient responsibility to appropriate team members.
• Participates in continuing education/ professional development activities.
• Learns and develops full knowledge of the CAAT Admission Processes and actively seeks to continuously improve them.
• Learns and has a full understanding of scheduling and pre-register routines in Meditech and any other referral platform utilized by the CAAT team (i.e., Referral Manager).
• Ad hoc duties as assigned that fall within scope of the CAAT team.

Qualifications

• High School Diploma or GED required, Associates or Bachelors Degree preferred; Preference towards a healthcare related area of concentration or be a licensed health care provider or equivalent experience.
• Certified Benefits Specialist, preferred.
• In lieu of a healthcare related field certificate, 2+ years of experience performing the functions of the role will be accepted.
• Experience in a healthcare-related area is strongly preferred.
• Ideal candidates will be highly detail oriented, have benefits, medical terminology, revenue cycle management, knowledge of post-acute care industry, and long-term acute care hospital experience.