Insurance Eligibility and Medical Billing Specialist

The Eligibility & Medical Billing Specialist reviews patient accounts, verifies insurance coverage, identifies billable insurance, and helps determine whether balances should be billed to insurance, returned to the provider, or pursued as patient responsibility.

Primary responsibilities include verifying patient insurance eligibility using Office Ally and payer portals, checking coverage for specific dates of service, reviewing commercial insurance, Medicare, Medicaid, Medicare Advantage, and secondary coverage. The specialist identifies payer mismatches, terminated coverage, coordination of benefits issues, and possible rebilling opportunities. Documentation of eligibility findings is maintained clearly in the collection system.

The role involves reviewing accounts before patient collection activity when insurance may be available, communicating with providers, billing departments, and internal collection staff. Assistance with claim status checks and flagging accounts for billing review, corrected claims, appeals, or secondary billing is also required. The specialist must maintain HIPAA-compliant handling of PHI and account documentation.

Success is measured by the accuracy and timeliness of eligibility checks, proper flagging of insurance-found accounts before collection, reduced incorrect patient responsibility pursuit, clear supporting documentation, and improved recovery through insurance identification and rebilling opportunities.

Physical requirements include the ability to work 40 hours per week during regular business hours, with possible evening and weekend work. The work environment is typical office with prolonged sitting and occasional lifting/moving up to 50 lbs.