Eligibility Specialist

Job Description

Job Description

The Eligibility Specialist is responsible for ensuring that accurate and complete insurance information is obtained and validated for new and existing patients receiving behavioral health services. This position serves as a critical front-end component of the insurance revenue cycle by identifying coverage, benefit, network, authorization, and payer requirements before services begin. The role will focus on reviewing automated results, resolving exceptions, identifying insurance-related barriers, and ensuring that required authorization workflows are initiated appropriately.

Essential Duties and Responsibilities

1. Complete insurance eligibility and benefit verification for new learners and existing learners as needed, utilizing Solum Health, payer portals, electronic eligibility systems, and other applicable resources.
2. Review and validate eligibility results, including member status, effective dates, plan information, benefits, coverage limitations, exclusions, and payer-specific requirements.
3. Identify primary and secondary insurance coverage, coordination-of-benefits considerations, and other factors that may affect coverage or reimbursement.
4. Verify provider and service location network status and identify potential out-of-network or other insurance-related barriers to services.
5. Identify insurance requirements that must be addressed prior to the start of services, including whether assessment or treatment authorization is required.
6. Partner with Intake, Clinical Operations, and Authorization teams to ensure insurance requirements, missing information, and potential barriers are identified and addressed before services begin.
7. Initiate and coordinate assessment authorization requests in accordance with applicable payer requirements and established workflows.
8. Monitor assessment authorization requests through determination, complete appropriate payer follow-up, and ensure approved authorizations are accurately documented and communicated to applicable teams.
9. Ensure required insurance and authorization documentation is obtained, accurately documented, and maintained in CentralReach and other designated systems.
10. Complete eligibility and benefit rechecks when insurance changes, coverage concerns, or other circumstances require validation, and identify changes that may affect existing services or authorizations.
11. Route insurance changes and authorization-impacting issues to the appropriate team for timely action.
12. Review automated eligibility and insurance transactions for accuracy and completeness, resolving exceptions that require manual intervention.
13. Identify recurring eligibility, payer, or automation issues and communicate trends and opportunities for process improvement to the Supervisor.
14. Utilize Solum Health, CentralReach, and other designated systems in accordance with established workflows, standard operating procedures, and payer-specific requirements.
15. Participate in testing, training, process improvement, and optimization of eligibility and intake insurance workflows, including the ongoing development and refinement of automated processes.

Qualifications:

• Strong understanding of health insurance eligibility, benefits, coverage limitations, exclusions, deductibles, and out-of-pocket requirements.
• Ability to accurately interpret insurance benefits and identify requirements that may impact access to behavioral health services.
• Strong understanding of the relationship between eligibility verification, benefit coverage, and assessment authorization requirements.
• Strong attention to detail and accuracy when reviewing insurance information, authorization requirements, and payer responses.
• Ability to recognize discrepancies, coverage issues, and potential barriers to services and appropriately escalate them for resolution.
• Excellent organizational and time-management skills, with the ability to prioritize multiple time-sensitive eligibility and assessment authorization requests.
• Strong written and verbal communication skills, with the ability to communicate insurance requirements clearly to families and internal teams.
• Ability to navigate payer portals, electronic eligibility systems, CentralReach, Solum Health, and other technology platforms while adapting to automated workflows.
• Demonstrated ability to work independently, exercise sound judgment, and follow established workflows while recognizing when an issue requires escalation.
• Ability to work independently while collaborating effectively with Intake, Clinical Operations, Credentialing, and Authorization teams.

Education/Experience Requirements

• High school diploma or equivalent required 
• Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred. 
• Minimum of one (1) year of experience in insurance, eligibility verification, medical billing, prior authorization, or a related field preferred.

Physical Requirements

While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time. The team member is occasionally required to stand, walk, and use hands to operate a computer keyboard. The team member may occasionally lift and or move up to 25 pounds. Vision requirements include close vision, distance vision, depth perception and the ability to adjust focus.

Company Overview:  

Lighthouse Autism Center is the leading Applied Behavior Analysis (ABA) therapy provider in Indiana, Iowa, North Carolina, Nebraska, Michigan, and Illinois and expanding within those states and other states across the U.S. Since 2012, Lighthouse Autism Center has provided the highest quality, center-based ABA therapy to children with autism. At Lighthouse, children work on things like social skills, daily living skills, communication skills, and school-readiness skills. All children are overseen by Board Certified Behavior Analysts and programs are implemented by Registered Behavior Technicians. Lighthouse Autism Center also has full-time Speech-Language Pathologists on staff who provide co-treat and consultative services speech therapy services to children who attend the centers.