Eligibility Specialist II

Western Growers Health; Irvine (CA); On-site; USD 45,000 - 60,000; Full time

Job summary

Western Growers Health is seeking an Eligibility Specialist II to support enrollment and billing operations, both automated and manual, within WGAT and PCMI accounts. The role handles EDI eligibility groups, provides client-facing support, and researches discrepancies in eligibility and billing while maintaining HIPAA safeguards.

The position emphasizes accurate processing, customer service excellence, and collaboration with internal teams to resolve inquiries and ensure timely payments.

Qualifications

• Experience handling enrollment and billing tasks in a processing environment.
• Ability to resolve billing discrepancies and respond to client inquiries.
• Strong customer service skills with HIPAA compliance awareness.

Responsibilities

• Process all enrollment and billing transactions including EDI as applicable.
• Research and resolve cash application and billing discrepancies; communicate with clients.
• Maintain HIPAA-compliant workstation and data security practices.
• Create and document Standard Operating Procedures (SOPs) and suggest improvements.
• Meet processing cycle times and audit standards to ensure accuracy and compliance.

Skills

Enrollment processing

Billing support

Customer service

HIPAA compliance

Tools

Genesys

HCPS system

Job description

Job Description Summary

This position reports to the Supervisor I, Enrollment and Eligibility. The Eligibility Specialist II requires the ability to process enrollment and billing functions, both automated and manual, with in the company’s processing system necessary to maintain Western Growers Assurance Trust (WGAT) and Pinnacle Claims Management, Inc. (PCMI) accounts) as assigned including groups that submit Electronic Data Interchange (EDI) eligibility. This role will provide customer service support to clients by instructing them on correct eligibility management and explaining billing and payment issues. They will also research and resolve eligibility and billing discrepancies or client inquiries.

This position reports to the Supervisor I, Enrollment and Eligibility. The Eligibility Specialist II requires the ability to process enrollment and billing functions, both automated and manual, with in the company’s processing system necessary to maintain Western Growers Assurance Trust (WGAT) and Pinnacle Claims Management, Inc. (PCMI) accounts) as assigned including groups that submit Electronic Data Interchange (EDI) eligibility. This role will provide customer service support to clients by instructing them on correct eligibility management and explaining billing and payment issues. They will also research and resolve eligibility and billing discrepancies or client inquiries.

Job Description Summary

This position reports to the Supervisor I, Enrollment and Eligibility. The Eligibility Specialist II requires the ability to process enrollment and billing functions, both automated and manual, with in the company’s processing system necessary to maintain Western Growers Assurance Trust (WGAT) and Pinnacle Claims Management, Inc. (PCMI) accounts) as assigned including groups that submit Electronic Data Interchange (EDI) eligibility. This role will provide customer service support to clients by instructing them on correct eligibility management and explaining billing and payment issues. They will also research and resolve eligibility and billing discrepancies or client inquiries.

Duties And Responsibilities

Department Operations

• Process all transaction types such as adds, terms, changes, carrier discrepancies and other eligibility related tasks for all lines of business, WGAT, and Pinnacle.
• Review and process all manual and/or EDI enrollment transactions (adds, changes, terminations) in HCPS as received from the client or internal sources in accordance with Participation Agreements, Employer Policy Statements, Eligibility Guidelines, and Summary Plan Descriptions.
• Research and correct cash application issues in company’s processing system. Determine and correct out of balance ledger items on accounts. Contact clients to explain and resolve billing and payment discrepancies. Verify or authorize refunds for terminations and overpayments.
• Perform full reconciliations on accounts in order to confirm that the group is in compliance.
• Maintain a HIPAA compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
• Meet processing cycle time standards and production due dates as set forth by management.
• Maintain performance in accordance with established quality standards, as measured by audit metrics. Consistently meet or exceed audit score requirements to ensure accuracy, compliance, and service excellence.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
• Create and document Standard Operating Procedures (SOP’s).
• Identify, initiate, and implement process improvements and/or innovation.

Customer Service

• Work with clients to facilitate payments on time and for the billed amount.
• Provide timely and effective Customer Service to clients for requests, inquiries, or issues concerning enrollment and/or billing items on their account via phone calls by logging into Genesys and taking calls based on daily phone schedule.
• Interface effectively with internal departments and external vendors, brokers, or other business contacts to coordinate interrelated activities and to resolve eligibility and/or billing issues as they arise.
• Serve as a representative of Wester Growers and PCMI displaying professionalism, knowledge, customer service, and discretion in all interactions with other members of the Western Growers/PCMI community and their customers.

Team Development

• Provide guidance, feedback, and support to new team members with processing and listening to their phone calls.
• Identify training deficiencies and provide feedback to administration leads.
• Provide backup as subject matter expert for new employees.
• Demonstrate support and collaboration within the team by offering assistance and providing resources when possible.

Other

• Maintain integrity and transparency in all tasks, ensuring alignment with team and organizational goals.
• Hold oneself accountable by taking ownership of actions, decisions, and their outcomes.
• Reflect on personal performance regularly, identifying areas for improvement and celebrating successes.
• Commit to continuous learning and growth, seeking feedback and implementing constructive changes.
• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA- required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

PHYSICAL DEMANDS/WORKENVIRONMENT

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.