Eligibility Specialist
Summary
Processes patient billing, verifies insurance, submits claims, and resolves denials while ensuring HIPAA and payer compliance.
Basic Job Description: The Eligibility Specialist is responsible for managing all aspects of patient billing, insurance verification, claims submission, and payment posting. This position ensures accurate and timely processing of claims while maintaining compliance with regulatory requirements and company policies. The specialist serves as the primary contact for patients, insurance companies, and internal staff regarding billing inquiries, denials, and account resolutions.
Essential Duties and Responsibilities
· Verify consumer insurance coverage and benefits prior to appointments.
· Prepare, review, and submit accurate insurance claims (electronic and paper) in a timely manner.
· Follow up on unpaid or denied claims, resolve discrepancies, and resubmit as needed.
· Process adjustments and reconcile discrepancies.
· Ensure compliance with federal, state, and payer regulations (HIPAA, Medicare, Medicaid, Managed Care Organizations).
· Maintain detailed documentation of billing activities.
· Collaborate with clinical and administrative staff to resolve billing or coding issues.
· Generate billing and financial reports as requested by management.
· Perform duties in accordance with company policies, procedures, and applicable regulations.
· Other duties as assigned by leadership.