ELIGIBILITY SPECIALIST

Position: Eligibility Specialist

Job Purpose:

Under close supervision of the Department Supervisor or Eligibility Lead, this positions works independently with all phases of routine assigned duties. May require occasional assistance with non-routine duties.

Job Duties:

• Performs all job duties for Eligibility Specialist
• Verifies eligibility and gives information to insured members and their families, medical providers, insurance carriers, government agencies, and union business agents using microfiche and teleprocessing equipment.
• Has a working knowledge of COBRA, HIPAA and FMLA and successfully completes all duties required to comply with these laws.
• Works with claims adjusters, insured members and data control personnel to assist in collecting delinquent hours and to adjust incorrect hours to the proper accounts. Follows up by advising insured members, claims personnel and others how adjustments and/or corrections may affect eligibility and claims payment.
• Prepares documentation for Account Executives for the appeal process.
• Processes self-payments by completing the necessary forms and other requirements. Advises insured members on correct payment amounts and the rules and regulations that apply to the payments.
• Processes death claims by forwarding necessary forms and beneficiary information to the insurance carriers involved. Handles any telephone calls, complaints, etc., on death claims between beneficiaries or members and insurance carriers.
• May require some use of microfiche and associated viewing equipment.
• Performs various typing assignments, prepares reports, and research projects as directed by the department manager.
• Process enrollment/beneficiary forms and other documents used for maintaining member records.
• Process medical I.D. cards.
• Perform other duties as assigned

Minimum Qualifications:

• Working knowledge of basic office equipment
• Demonstrates ability to keep calm and positive within all communications.
• Demonstrates ability to establish and maintain effective working relationships with internal staff and external clients.
• Proven ability to accurately and timely review and accounting information and documentation.
• Utilize computer and phone systems to be able to effectively perform the essential functions of the position
• 3 years of office work with 1 year working within a high call volume environment or successfully completed internal Eligibility Specialist Trainee designation.
• Requires a dependable attendance record.
• Requires excellent skills in grammar, letter composition, punctuation, and other related office skills.
• Demonstrates initiative along with good concentration, attention to detail and problem-solving abilities.
• Requires excellent organizational skills and the ability to multi-task.

Preferred Qualifications:

• Associates degree
• 2-4 years of experience in a medical environment dealing with a high volume of calls 50-60 calls per day.

Physical/Mental Requirements:

• The physical and mental demands described here are representative of those that must be met by employees to successfully perform the essential functions of this job.
• While performing the duties of this job, employees are regularly required to use written and oral communication skills; read and interpret data, information, and documents; analyze and solve non-routine and complex office administrative problems; use math and mathematical reasoning; observe and interpret situations; learn and apply new information or skills; perform highly detailed work on multiple, concurrent tasks; work under intensive deadlines with frequent interruptions

Work Environment:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this class. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Employees work under typical office conditions, and the noise level is usually quiet.
• WPAS is an equal opportunity employer. We celebrate diversity and strive to continually create the most inclusive work environment for all our employees.