Eligibility and Risk Specialist

Eligibility and Risk Specialist – Valencia, CA Responsible for verifying eligibility and risk delegation for health plan members and properly maintaining customer records. Research rejections and denials and make necessary corrections to meet billing guidelines or recommend claims for write-off. Job Responsibilities Verify eligibility and risk delegation for health plan members and maintain customer records. Ensure all eligibility verification requests are completed timely. 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 using web portals, phone contact, EOBs, provider manuals, etc. Adjudicate claim issues by preparing and submitting corrected claims or appeals. Recommend claims for write‑off when billing requirements are not met. 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, 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 and billing requirements preferred. Proficiency in Microsoft Office, especially Excel. Detail oriented, thorough, accurate, and organized. Proven ability to research and solve problems. Good written and verbal communication skills. Pay & Benefits $19‑20 per hour. Medical, Dental, and Vision. 401(k) with company match. Sick and vacation days. Flexible Spending Account. Life and disability insurance. Education assistance. Employee referral program. #J-18808-Ljbffr Shield HealthCare - Medical Supplies for Care at Home Since 1957