Eligibility Specialist

We are partnering with a mission-driven healthcare organization dedicated to providing high-quality health and welfare benefits to an essential and underserved workforce. This organization plays a critical role in ensuring access to care for thousands of individuals and families, offering stability and support through comprehensive benefits programs.

This is an opportunity to join a purpose-driven team where your work directly impacts lives-helping members understand and access the healthcare they depend on.

Position Overview

The Healthcare Insurance Eligibility Specialist serves as a key liaison between members, employers, and healthcare providers. This role is responsible for verifying eligibility, maintaining accurate records, and guiding members through their healthcare coverage with clarity and empathy.

The ideal candidate is detail-oriented, bilingual (Spanish/English), and passionate about helping others navigate complex systems.

Key Responsibilities

• Review and process employer-reported work hours to determine member eligibility based on plan rules and agreements
• Maintain accurate eligibility records, including demographics, dependents, and coverage timelines
• Investigate and resolve discrepancies affecting eligibility status
• Generate and distribute eligibility data to vendors (pharmacy, dental, vision, etc.)
• Assist members in understanding benefits, coverage periods, and out-of-pocket costs in clear, simple terms
• Support enrollment processes, including self-pay and COBRA options
• Coordinate benefits with state programs (e.g., Medi-Cal)
• Handle sensitive coverage issues with professionalism and empathy
• Respond to provider inquiries regarding eligibility and benefit verification
• Partner with internal teams to resolve claims-related eligibility issues
• Ensure compliance with HIPAA and other regulatory requirements
• Conduct audits and maintain organized, secure member records

Required Qualifications

• High school diploma or GED required; associate's or bachelor's degree preferred
• 2-3+ years of experience in health insurance eligibility, medical billing, or a related healthcare setting
• Fluent in Spanish and English (required)
• Proficiency with Microsoft Office (Excel, Word, Outlook)
• Familiarity with healthcare systems or databases (e.g., QNXT, Facets, CRM tools)
• Working knowledge of:
• Medical terminology
• HIPAA regulations
• Health insurance basics (deductibles, co-pays, HMO/PPO structures)

Preferred (Nice to Have)

• Experience with union trust funds or similar benefit plans
• Background supporting underserved or community-based populations
• Familiarity with electronic data interchange (EDI) or eligibility systems

Why This Role Stands Out

• Strong benefits package including medical, dental, and vision
• Retirement plan with employer contribution
• Generous paid time off
• Stable, mission-driven organization
• Meaningful work supporting essential workers and their families