Insurance Verification & Benefit Manager

Role Responsibilities

• Oversee insurance verification, eligibility determination, and benefits investigation workflows across commercial, Medicare, Medicaid, and managed care payers
• Verify patient insurance coverage using payer portals, clearinghouses, and EDI 270/271 real-time eligibility transactions
• Identify and resolve coordination of benefits issues, coverage gaps, and eligibility discrepancies prior to service delivery
• Evaluate and annotate AI-generated eligibility verification outputs for accuracy, completeness, and payer compliance
• Develop and document SOPs for eligibility and benefits verification workflows
• Monitor KPIs including verification accuracy rates, front-end denial rates related to eligibility, and turnaround times
• Ensure compliance with payer-specific requirements, CMS guidelines, and HIPAA regulations
• Identify process gaps and recommend workflow improvements to reduce eligibility-related claim denials
• Provide structured feedback and annotations to support AI training datasets

Good Candidature

• 5+ years of experience in insurance verification, eligibility and benefits management, or front-end revenue cycle operations, with at least 2 years in a management role
• Expert knowledge of EDI 270/271 transactions, payer portal navigation, and real-time eligibility tools
• Strong familiarity with Medicare, Medicaid, and commercial payer eligibility requirements and benefit structures
• Proficiency with Epic, Cerner, Meditech, or equivalent EHR platforms
• Experience with clearinghouse platforms such as Availity, Change Healthcare, or similar
• Exceptional written and verbal English communication skills
• High attention to detail with the ability to identify subtle discrepancies in coverage data

Nice to Have

• CHAM, CHAA, or equivalent front-end revenue cycle certification
• Experience with automated eligibility verification tools and RPA solutions
• Background in denial root cause analysis related to eligibility and coverage errors
• Familiarity with AI tools and comfort evaluating AI-generated healthcare content
• Experience presenting eligibility performance data to senior leadership