Insurance Verification & Benefit Manager | Mercor

Key Responsibilities

• Oversee end-to-end insurance verification, eligibility determination, and benefits investigation across commercial, Medicare, Medicaid, and managed care payers, with accountability for front-end denial rate reduction.
• Execute and validate real-time eligibility transactions via EDI 270/271, payer portals, and clearinghouse platforms, resolving coordination of benefits conflicts and coverage discrepancies prior to service.
• Evaluate and annotate LLM-generated eligibility verification outputs for accuracy, completeness, and payer compliance, contributing structured feedback to model training datasets.
• Develop and maintain SOPs governing eligibility and benefits verification workflows, ensuring alignment with CMS guidelines, payer-specific requirements, and HIPAA regulations.
• Monitor and report on KPIs including verification accuracy rates, eligibility-related denial rates, and turnaround times, presenting performance insights to senior stakeholders.
• Identify systemic process gaps and recommend workflow improvements that reduce eligibility-driven claim denials across the revenue cycle.

Core Requirements

• Expert-level command of EDI 270/271 transactions, real-time eligibility tools, and payer portal navigation across commercial, Medicare, and Medicaid benefit structures.
• Demonstrated management-level responsibility within front-end revenue cycle operations, including direct oversight of verification workflows and team performance.
• Proficiency with Epic, Cerner, Meditech, or equivalent EHR platforms in a high-volume eligibility environment.
• Hands-on experience with clearinghouse platforms such as Availity or Change Healthcare.
• Prior exposure to RPA solutions or automated eligibility verification tools in a healthcare context.
• Proven ability to detect subtle discrepancies in coverage and eligibility data with high precision and consistency.

Additional Strengths

• CHAM, CHAA, or equivalent front-end revenue cycle certification preferred.
• Background in denial root cause analysis tied to eligibility and coverage errors.