Healthcare Eligibility Specialist

ProCare Pharmacy Benefit Manager, Inc.; Gainesville (GA); Hybrid; USD 42,000 - 54,000; Full time

Job summary

ProCare Pharmacy Benefit Manager, Inc. is seeking an organized office professional to manage member eligibility processes and support client onboarding in a health plan environment.

The role requires strong communication, attention to detail, and the ability to coordinate with pharmacies, plan members, and internal teams to ensure accurate data and timely enrollment updates. Candidates with health insurance background and familiarity with eligibility systems will excel in fast-paced environment.

Qualifications

• High school diploma or equivalent required.
• Post high school or specialized training in medical field desired.
• Minimum three years experience in a customer service position, preferably as an Office Manager or a similar service position in the health care industry.
• Must have excellent communication skills and the ability to work effectively with clients, pharmacies, and plan members, internal and external contacts.
• Proficient PC skills in Windows-based applications.
• Health insurance background and knowledge of pharmacy terminology desired.
• Ability to be flexible and quickly adapt to changing needs in department.
• Must be highly organized with strong attention to detail.
• Must be flexible with scheduled work hours.

Responsibilities

• Coordinates the input of member eligibility for all new groups
• Assists with the implementation process for new clients
• Coordinates with client contacts to ensure information is received is accurate and timely
• Enrolls on-line management (Portal) users and maintains accounts
• Enrolls new members and/or processes terminations
• Works with multiple departments to coordinate eligibility requirements
• Utilizes both manual and systematic enrollment process
• Reviews daily reporting for eligibility corrections
• Answers incoming telephone calls related to eligibility needs
• Ensures eligibility systems are updated and data is appropriately integrated on a daily basis
• Maintains the eligibility files for medical coverage recipients (PHI)
• Handles escalated eligibility issues to ensure problems are resolved
• Ensures that all correspondence and eligibility files are properly maintained
• Perform scheduled review and quality assurance for member eligibility
• Assist with go-lives and testing data files
• Performs various related duties as assigned including but not limited member communications, personal importation, overflow IC phone support, pharmacy network tasks; etc.

Skills

Excellent communication

Customer service

Organizational skills

Attention to detail

Adaptability

Flexibility with schedule

Education

High School Diploma

Post-high school training in medical field

Tools

Windows-based applications

Job description

ProCare Pharmacy Benefit Manager, Inc. is seeking an organized office professional to manage member eligibility processes and support client onboarding in a health plan environment.

The role requires strong communication, attention to detail, and the ability to coordinate with pharmacies, plan members, and internal teams to ensure accurate data and timely enrollment updates. Candidates with health insurance background and familiarity with eligibility systems will excel in fast-paced environment.