About this role

Verify patient insurance coverage through payer websites, clearinghouses, and direct communication with insurance representatives
Confirm eligibility, benefits, coverage limitations, copayments, coinsurance, deductibles, and out-of-pocket responsibilities
Identify primary, secondary, and tertiary insurance coverage
Review policy effective dates and ensure insurance information is current and accurate
Determine coverage for scheduled procedures, treatments, diagnostic services, and specialty care
Verify benefit limitations, exclusions, medical necessity requirements, and referral requirements
Communicate benefit information to patients, providers, and internal teams
Accurately document eligibility and benefits verification findings within practice management or electronic health record (EHR) systems
Maintain detailed records of payer contacts, reference numbers, and verification outcomes
Ensure compliance with HIPAA, organizational policies, and payer guidelines
Collaborate with scheduling, registration, billing, and coding teams to prevent claim denials related to eligibility issues

High school diploma or equivalent
Minimum 1–3 years of healthcare insurance verification, eligibility, benefits investigation, patient access, or revenue cycle experience
Knowledge of commercial insurance, Medicare, Medicaid, Managed Care, and government healthcare programs
Understanding of insurance terminology, including deductibles, copayments, coinsurance, referrals, and prior authorizations
Proficiency with payer portals, clearinghouse tools, EHR systems, and Microsoft Office applications
Preferred Associate's or Bachelor's degree in Healthcare Administration, Business, or related field
Certification in healthcare revenue cycle, patient access, or medical office administration
Experience in specialty healthcare services, hospital, physician practice, or ambulatory care settings

Healthcare Insurance Eligibility and Benefits Specialist

Key skills