Eligibility Specialist

Job Summary:The Eligibility Specialist will process benefit entries and validate information. This role will respond to eligibility and other enrollment related issues involving member specific information; partner directly with clients, and/or vendors, to resolve problems and achieve positive outcome. Duties and Responsibilities:Perform eligibility additions, terminations, and changes for new and renewal clients from electronic files, paper forms and portal. Confirm that enrollments or changes are made according to legal or client specifications. Validate enrollments to ensure that they are activated timely, and that information is correctly and completely entered. Verify that information needed for data transfer to affiliated vendors is included. Stay informed about current and evolving regulations impacting the insurance industry, including, but not limited to, state insurance codes, federal regulations (e.g. HIPAA) and other relevant laws to ensure compliance rules are strictly followed.Provide feedback on implementations and renewals for eligibility processing to improve processes, workflows, and products.Interpret and analyze data from multiple sources including claims, provider, member, and encounters data. Identify and perform root-cause analysis of data irregularities and present findings and proposed solutions to leadership and/or customers.Interface with providers, vendors, and internal departments to address billing or technical issues related to eligibility.Create and maintain system access logons for Brokers and Clients.Receive and respond to inquiries and data transfers from clients meeting department turn-around time for responses and queue levels.Support team with review of system configuration and processes to ensure optimum processing.Manage multiple deadlines associated with differing tasks using proficient time management and organizational skills.Create ID cards for new and renewal business ensuring that the templates are built completely and accurately. Release ID Cards timely and report any backlogged cards or issues to management immediately. Audit and validate ID card processing ensuring released cards meet end user expectations and template requirements. Generate and mail required notices for all product lines.RequirementsRequired Knowledge, Skills, and Abilities:High school diploma or equivalent2 years of experience in eligibility, enrollment, ID card configuration or benefits customer service role focused on eligibilityKnowledge of health insurance plans and employee benefits Experience with benefit administration platforms such as Javelina preferredSolid working knowledge of standard computer applications including MS Word, Excel, Outlook, and PowerPointAbility using a computer which includes expert keyboard and navigation skills and learning new programsCommunicate clearly and professionally with internal and external customersWork effectively as part of a team to achieve established outcomes. Understand other's roles and empower one another to take responsibility to be successful. Demonstrate a collaborative interaction with peers to reach a common goal as well as be a resource to team members and internal/external customersPay close attention to detail in all aspects of the jobMake decisions using available resources and sound judgment Maintain confidentiality and discretionIdentify and resolve problems in a timely manner, gather and analyze information skillfullyShare knowledge with associates by effectively communicating and providing follow-upOpen to other's ideas and exhibits a willingness to try new things.Demonstrate accuracy and thoroughness; monitor work to ensure quality.Prioritize and plan work activities to use time efficiently.Adapt to changes in the work environment, manage competing demands and is able to deal with frequent change, delays, or unexpected events.Follows instructions, responds to direction, and solicits feedback to improve.Act in such a way to instill trust from management, other associates, as well as customers. Work overtime as required, including evenings and weekends as business needs dictate.Physical and Cognitive Demands: The demands described here are representative of those necessary for an employee to successfully perform the essential functions of this job. Reasonable accommodation can be made to enable individuals with disabilities to perform the essential functions.Constant: Talk, hear, speak, and use hands and fingers to operate a computer, telephone, keyboard/mouse; occasionally move about the officeConstant: Visual ability such as close vision, distance vision, color and peripheral vision, depth perception and ability to adjust focusOccasional: Lift and/or move up to 10 poundsConstant: Regular, predictable attendance is requiredConstant: While performing the duties of this job, the employee is regularly sitting for the full shift.Constant: The cognitive skills needed to complete tasks include abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending. Work Environment: The work environment described is representative of what must be met by an employee successfully perform the essential functions of this job. The physical environment is indoors in a controlled climate, office setting. The noise level may be low to moderate.The duties described are representative, but not restrictive of tasks that may be assigned or of the abilities required to do the job. The description is subject to change at any time. Other related duties may be assigned. This description does not alter the at-will status of employment.

Created: 2026-04-02