Eligibility and Risk Specialist

Shield HealthCare; Washington (IL); On-site; USD 26,174 - 27,552; Full time

Benefits offered by this job

Medical, Dental, and Vision

401(k) with Company Match

Sick and Vacation Days

Flexible Spending Account

Life & Disability Insurance

Education Assistance

Employee Referral Program

Job summary

Shield HealthCare is seeking an Eligibility and Risk Specialist in Valencia, CA, responsible for verifying eligibility and managing health plan member records. This role involves researching claim issues, ensuring compliance with billing requirements, and maintaining positive relationships with third-party payers.

The ideal candidate will have strong communication skills, attention to detail, and proficiency in Microsoft Office. This is a full-time, on-site position offering competitive pay and benefits, including medical, dental, retirement plans, and education assistance.

Qualifications

• Familiarity with various medical insurance payer guidelines and billing requirements preferred.
• Proficiency in Microsoft Office, with experience in Microsoft Excel.
• Must be detail-oriented, thorough, accurate, and organized.

Responsibilities

• Responsible for verifying eligibility and risk delegation for health plan members.
• Ensure that all eligibility verification requests are completed timely.
• Research problems related to eligibility claim rejections and denials.
• Maintain accurate records of customer accounts.

Skills

Familiarity with medical insurance payer guidelines

Proficiency in Microsoft Office

Detail oriented and organized

Research and problem-solving skills

Good communication skills

Job description

Eligibility and Risk Specialist

Location: Full Time Clerical Valencia, CA, US

Salary Range: $19.00 To $20.00 Annually

Shield HealthCare is looking for an Eligibility and Risk Specialist in Valencia, CA responsible for verifying eligibility and risk delegation for health plan members and properly maintaining customer records. Research related rejections and denials and make necessary corrections to meet billing guidelines or recommend claims for write‑off.

This position is on‑site in Valencia, CA.

Job Responsibilities

• Responsible for verifying eligibility and risk delegation for health plan members and properly maintaining the customer records
• Ensure that all eligibility verification requests are completed in a timely manner
• Research problems and find solutions to eligibility related claim rejections and denials
• Inform management of changes or trends with eligibility and risk issues
• Research denials and billing requirements of third-party carriers utilizing web portals, phone contact, EOBs, provider manuals, etc.
• Adjudicate claims issues by preparing and submitting corrected claims or appeals
• Recommend claims for write‑off when billing requirements are not met
• Effectively communicate by phone, email, and in‑person with third‑party payers and internal staff to resolve eligibility issues and establish positive relationships
• Accurately update and notate accounts receivable system, collections notepad, and customer accounts
• Remain updated on company policies and procedures and third‑party payer guidelines, bulletins, and billing requirements
• Work reports and projects assigned by management
• Ensure appropriate follow‑up and timely completion of assignments

Qualifications

• Familiarity with various medical insurance payer guidelines/billing requirements preferred
• Proficiency in Microsoft Office with experience working in Microsoft Excel
• Must be detail oriented, thorough, accurate, and organized
• Proven ability to research and solve problems
• Good written and verbal communication skills

Pay & Benefits

• $19-20 / hour
• Medical, Dental, and Vision
• 401(k) with Company Match
• Sick and Vacation Days
• Flexible Spending Account
• Life & Disability Insurance
• Education Assistance
• Employee Referral Program