What are the responsibilities and job description for the Insurance Eligibility Specialist position at PRESTIGE HEALTHCARE RESOURCES INC?
Insurance Eligibility Specialist
Department: Administrative / Billing
Reports To: Intake Manager
Who We Are
Prestige Healthcare Resources, Inc. (PHRI) is a leading behavioral healthcare organization dedicated to improving the lives of individuals and families across the District of Columbia. We provide high-quality, person-centered services and rely on accurate insurance verification to ensure our Consumers receive timely access to care without disruption.
The Insurance Eligibility Specialist plays a vital role at the front end of service delivery and billing accuracy. By ensuring all Consumers have active insurance coverage and resolving eligibility issues proactively, this position directly supports service continuity, organizational compliance, and reimbursement integrity.
What You’ll Do
As the Insurance Eligibility Specialist, you will be responsible for verifying and maintaining accurate insurance information for all new and existing Consumers across all PHRI programs. You will prevent disruptions in care, support billing operations, and ensure compliance with payer and regulatory standards.
Insurance Verification & Coverage Management
Verify insurance eligibility for all new Consumers.
Conduct ongoing reverification for existing Consumers according to agency timelines.
Confirm coverage through payer portals, clearinghouses, and verification tools.
Identify benefit limitations and prior authorization requirements and notify appropriate staff.
Eligibility Review, Updates & Documentation
Maintain accurate, up-to-date payer information within the EHR.
Process and document payer changes promptly and accurately.
Track and address upcoming coverage expirations or lapses.
Document all verification actions per DC MHRS and HIPAA standards.
Consumer Assistance & Communication
Contact Consumers to obtain missing information or resolve insurance discrepancies.
Provide guidance on enrollment, reinstatement steps, or coverage issues.
Help Consumers understand payer rules affecting service access.
Collaboration & Coordination
Work closely with intake, clinical, billing, and administrative teams.
Notify staff promptly when insurance issues impact service eligibility or billing.
Collaborate with billing teams to minimize denials related to eligibility errors.
Problem Resolution & Payer Follow-Up
Research and resolve eligibility discrepancies with payers.
Escalate complex eligibility cases as needed.
Assist billing staff with claim denials related to insurance eligibility.
Compliance, Reporting & Quality Assurance
Adhere to DC MHRS, Medicaid/MCO, and agency standards.
Generate eligibility status reports and summaries of unresolved issues.
Ensure documentation is audit-ready for internal or external reviews.
Monitor payer policy changes and share updates with relevant staff.
Process Improvement
Recommend workflow enhancements to strengthen accuracy and efficiency.
Participate in ongoing training and system updates related to insurance verification.
What You’ll Bring
High school diploma or equivalent required; Associate’s or Bachelor’s degree in healthcare administration, business, or related field preferred.
1–2 years of experience in insurance verification, eligibility determination, or medical billing within healthcare or behavioral health.
Strong knowledge of DC Medicaid, Medicare, MCOs, and commercial insurance highly preferred.
Experience using EHR systems and Microsoft Office Suite.
Exceptional attention to detail and accuracy in data entry and documentation.
Strong communication and customer service skills.
Ability to handle confidential information with professionalism.
Ability to work independently and collaboratively within multidisciplinary teams.
Why Prestige
Impactful work: Your accuracy ensures Consumers can access uninterrupted behavioral health services.
Strong team environment: Work closely with intake, billing, and clinical teams in a collaborative, supportive atmosphere.
Professional growth: Opportunities to deepen expertise in insurance, compliance, Medicaid/MCO processes, and behavioral health operations.
Mission-focused organization: Join a company committed to empowering individuals and improving community well-being.
Operational excellence culture: Your contributions directly support compliance, reimbursement integrity, and high-quality care delivery.
Core Competencies
1. Insurance & Payer Knowledge
Understands Medicaid, Medicare, MCO, and commercial insurance eligibility rules, coverage requirements, and verification processes; applies this knowledge accurately in daily work.
2. Accuracy & Data Integrity
Maintains precise documentation, performs thorough eligibility checks, and ensures all insurance information in the EHR is complete, current, and compliant.
3. Critical Thinking & Problem Solving
Identifies discrepancies quickly, investigates complex payer issues, and resolves eligibility challenges through effective follow-up with Consumers and payers.
4. Consumer Communication & Support
Communicates clearly and respectfully with Consumers about insurance requirements, missing information, and steps needed to secure or reinstate coverage.
5. Collaboration & Teamwork
Works effectively with intake, clinical, billing, and administrative teams to support coordinated service delivery and prevent billing denials.
6. Compliance & Confidentiality
Adheres to DC MHRS, HIPAA, Medicaid, and agency standards; handles all Consumer and payer information discreetly and responsibly.
7. Organization & Time Management
Manages multiple verifications, reverifications, deadlines, and follow-up tasks efficiently in a fast-paced environment.
8. Technical Proficiency
Uses EHR systems, payer portals, clearinghouses, and Microsoft Office tools effectively to perform eligibility verification and documentation tasks.
Equal Opportunity Statement:
Prestige Healthcare Resources is an Equal Opportunity Employer. We value diversity and encourage applications from all qualified individuals regardless of race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status.
Salary : $25 - $26